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A 



PRACTICAL TREATISE 



ON 



ENTERIC FEVER 



" It has long been a matter of regret that medical practitioners, generally, bo 
not pat greater attention to recording ststematic notes of their more im- 
PORTANT cases." — Tanner. 



PRACTICAL TREATISE 



ENTEEIC FEVEK 



DIAGNOSIS AND TREATMENT 



AN ANALYSIS OF ONE HUNDRED AND THIRTY CONSECUTIVE 
CASES, DERIVED FROM PRIVATE PRACTICE, 



AND EMBRACING A 



PARTIAL HISTORY OP THE DISEASE IN VIRGINIA. 



BY 



JAMES E. REEVES, M.D 




PHILADELPHIA: - 

J. B. LIPPINCOTT & CO. 
1859, 



If $ 



■^ 



Entered, according to Act of Congress, in the year 1859, by 

J. B. LIPPINCOTT & CO., 

In the Clerk's Office of the District Court of the United States for the Eastern District 
of Pennsylvania. 



TO THE 

MEDICAL SOCIETY OF VIRGINIA, 
f |is WfStl 

IS 

RESPECTFULLY DEDICATED 

BY 

THE AUTHOR. 



PREFACE. 



The following volume is an enlarged account of the cases of 
enteric fever reported in 1856 for the Buffalo Medical Journal. 

Since the publication of that Eeport, I have received letters 
from gentlemen of the profession, both in and out of the State, 
requesting that I would pursue the subject to greater length. 
In obedience to this request I now submit to the profession, in 
separate form, my experience, together with such statistical data 
concerning the disease, as I have been able to collect from the 
various sections of the State. 

But, it may be asked, why serve it up in boolc form ? Why 
another volume on enteric fever after the ample accounts of the 
disease given by Dr. Bartlett in his work on Fevers, and by Dr. 
Wood in his work on Practice, both paragons of American 
medical learning ? If so, I reply that the material out of which 
this volume is compiled, has been collected in private practice — 
rural practice — and in a region of country where, on account of 
the frequency of the disease during the past fifteen years, exten- 
sive opportunities have been afforded for a thorough understand- 
ing of its symptoms, uncontrolled by the influences that operate 
in the production, march, and termination of the disease, in city 
and hospital practice. Again, if the accounts given by these 

(vii) 



Vlll PREFACE. 

and other writers be supported by country experience, is it not 
desirable that their labors should be indorsed by this testimony? 
If they differ in any particular, however slight, should this not 
also be known ? The lovers of medical truth will answer. 

The little volume herewith submitted is just as plain and 
simple a statement of an important disease as I could make. 
Its facts have been gathered at the bedside of the rich, and the 
very poor — in the well situated and comfortable dwelling, and in 
the unfavorably situated and poorly constructed cabin-house, 
and among all ages. 

The importance of country practice in arriving at the true 
character of any given disease, is everywhere acknowledged ; yet 
how small is the harvest, considering the number of laborers' 
employed ! In Virginia, as in many of the other States, private 
'practice may well nigh be considered a sealed book, and that 
this should be the case is indeed unfortunate for the advance- 
ment of our knowledge of disease. It is a lamentable fact that 
when the best of country physicians die, their experience, valu- 
able sometimes, as it is hard earned, generally dies with them ; 
they are of much service while living, but afterwards, for all the 
good they have done to advance the profession, it was as well 
they had not lived. They have been like the sunlight on the 
wall, which comes and goes and leaves no mark behind ; or the 
shadow on the shore, which silently passes and disappears, 
leaving no footprint to indicate its course on the sands. A few, 
however, have shed lustre on their names and calling, and left 
an impression for good that will remain ; but alas ! what a vast 
number have left no trace of their professional existence ! - There 
is this reason, perhaps, for the manifest indolence of country 
practitioners in recording their experience. It is the custom to 
estimate themselves as necessarily occupying an inferior position 



PREFACE. ix 

in the profession, and they look up to the professors of their Alma 
Mater, and to the professors of the schools generally, with a sort 
of reverential awe. They esteem the intelligent labors of these 
gentlemen not too highly, but to the exclusion of their own worth, 
and the eligibility of their positions for the performance of good 
works, which, if industriously improved, by imitating the ex- 
ample set before them by those whom they are accustomed to 
deem their superiors, would not only prove of inestimable value 
to themselves, but forward the progress of their art, and espe- 
cially tend to increase our knowledge of diagnosis and thera- 
peutics. 

Such is the extent of the apathy which prevails among the 
members of the medical calling, that our literature is almost en- 
tirely wrought from the labors of the few — professors of schools, 
and those in charge of hospitals. Were it not for the laudable 
endeavors of these men, we should not have an American medical 
literature. 

In many of the States the profession is represented by one or 
more well conducted journals. These are the willing recipients 
of all that may seem of importance, even down to the humblest 
walks of the profession. There being no excuse for so much un- 
profitable silence, as at present exists, let us therefore speedily 
shake off our lethargy and elect to become useful members in the 
largest and best sense of the term. Let us individually and col- 
lectively, as students and practitioners, strive to improve our art, 
and each, being armed with the segis of truth, contend one with 
the other for the greatest amount of carefully collected material 
for the completion of that great national medical edifice whose 
foundation-stones have been laid broad and deep by our venera- 
ble fathers. 

If by the presentation of this little volume I can call the 



X PREFACE. 

• 
attention of my country colaborcrs to the importance of record- 
ing systematic notes of their experience, I shall have performed 
a satisfactory labor. 

For the arrangement of its contents I offer no apology, ex- 
cept that the one chosen seemed most natural and easiest of 
description. 

To make it the more complete and convenient I have not hesi- 
tated to quote largely in the production of some of its chapters. 
Wherever I have quoted, I have always endeavored to acknow- 
ledge the authority. If, however, I have made any omissions in 
this respect, it has been done accidentally, or because I have 
considered whatever was thus employed common property. 

To the gentlemen in the different sections of the State who so 
kindly and promptly responded to my interrogatories concerning 
the disease in their respective localities, I am under many obli- 
gations, not only for the valuable assistance afforded, but for 
their kind wishes for the success of the undertaking. 

JAMES E. REEVES. 
Phtlippi, Va., April. 1S59. 



CONTENTS. 



CHAPTER I. 

PAGE 

Preliminary Matters 13 

CHAPTER II. 

Symptomatology of Enteric Fever : I. Of the Mild Form — 
II. The Intermediate Form— III. The Malignant Form 17 

CHAPTER III. 

Recapitulation of Symptoms : 1. Headache — 2. State of the Mind 
and Senses — 3. Prostration of Muscular Strength — 4. State of 
the Pulse — 5. Cough and Bronchial Rales — 6. Diarrhoea — 
7. Tympanites — 8. Rose-colored Eruption — 9. Hemorrhage — 
10. Tendency to the Formation of Eschars 35 

CHAPTER IV. 
Anatomical Lesions 63 

CHAPTER V. 
History and Causes: 1. Localities — 2. Season — 3. Contagion — 
4. Exemption from Second Attacks — 5. Age — 6. Sex — 7. Expo- 
sure — 8. Recency of Residence — 9. Race 72 

CHAPTER VI. 

Duration and Complications 101 

(xi) 



Xll CONTENTS. 

CHAPTER VII. 

PAGE 

Terminations and Seguelse : 1. Convalescence — 2. Death — 3. Se- 
quelae no 

CHAPTER VIII. 
Diagnosis — Mortality and Prognosis — Nature 118 

CHAPTER IX. 

Treatment : Prefatory Remarks — Therapeutic Processes and 
Agents : 1. Emetics — 2. Purgatives — 3. Blood-letting — 4. Dia- 
phoretics — 5. Veratrum Viride — 6. Astringents — 7. Fomenta- 
tions — 8. Blisters — 9. Oil of Turpentine — 10. Chlorate of 
Potash — 11. Tonics and Stimulants — Dietetic Management — 
Management of Complications — Outline of Treatment: 1. The 
Mild Form — 2. The Intermediate Form — 3. The Malignant 
Form 135 

CHAPTER X. 
Management of Convalescence 193 



ENTERIC FEVER, 



CHAPTER I. 

PRELIMINARY MATTERS. 

Following the example of Dr. Wood, I denominate 
the disease to be described in the following pages, 
Enteric Fever. A vast amount of learning has been 
expended upon the nomenclature of the disease, which, 
unfortunately, instead of elucidating, has obscured it. 
The name typhoid fever, although objectionable, is in 
common use. In a private letter to the author, Dr. 
Wood remarks: "The name typhoid fever, was given 
by Louis in ignorance of a part of the ground ; for he 
did not know, certainly, that another fever existed which 
ought to be called typhus; and in this uncertainty he 
named it typhoid, so as to convey, at any rate, the idea 
of analogy, if not identity, with what had previously 
been called typhus. Now that the fact is recognized, 
that these are two wholly distinct diseases, it seems to 

2 



14 ENTERIC FEVER. 

me quite unphilosophical to give to one of them a name 
from its supposed resemblance to the other. We say 
varioloid very properly, because the affection so called 
is a modification of variola, and depends on the same 
cause ; but the typhoid is not a modification of typhus, 
and depends on a different cause. It is true that, in 
some cases, and in certain symptoms, it is like typhus ; 
but scarcely more than it is, in other instances, like 
miasmatic remittent. It is certainly, I think, not more 
like typhus than roseola is like scarlatina; and yet 
we do not call the former scarlatinoid, or the latter 
roseoloid. Besides, the word typhoid has before been 
applied to a state occurring in numerous febrile diseases, 
resembling that of typhus : as a typhoid state of pneu- 
monia, dysentery, bilious fever, etc. etc., and its appli- 
cation to any one disease at present may lead to confu- 
sion, as, in fact, it often has led, in the mind of the 
learner." The name enteric fever, I think, is unobjec- 
tionable, and will ultimately triumph, "as," in the 
language of Dr. Wood, "it merely indicates that the 
intestinal affection is characteristic, as in the case of 
smallpox, which we name from the eruption." Without 
further apology for the choice of this name for the dis- 
ease, I shall at once proceed to classify its different 
forms, and describe the symptoms peculiar to each. 
I propose a division of the symptomatology of enteric 
fever into three distinct forms : — 



PRELIMINARY MATTERS. 15 

1st. The Simple, or Mild. 

2d. The Intermediate. 

3d. The Malignant, including the Fatal. 

This arrangement I think will be found preferable to 
any which our authorities supply. After a very limited 
experience at the bedside, I learned to recognize the 
disease in these forms, the correctness of which distinc- 
tion a more enlarged service has abundantly verified. 

I admit, however, that in some instances it may be 
difficult to say where the line is to be drawn, so very 
gradual is the transition from the one form into the 
other ; but in the large majority of cases there is but 
little difficulty in recognizing it. During some seasons 
I have observed the character of the disease to be mild 
throughout ; at other times the majority of cases occur- 
ring, passed rapidly into the intermediate form ; and at 
others, either a tendency to still be protracted into the 
severer form, the malignant, or to assume this character 
in the beginning. Again, I have seen the disease 
prevail when the medical constitution did not seem to 
influence or favor the development, in the majority, of 
either form, but would appear in all, the force of the 
poison expending itself according to the peculiar apti- 
tude or idiosyncrasy of each individual patient. When 
this was the case in the same family, I have had a 
patient suffering from the mild form; another, in which 
the disease, having been mild for a longer or shorter 



16 ENTERIC FEVER. 

time, passed into the intermediate form; another, in 
•which there was a rapid march through the milder forms 
into the malignant ; and another, in which the disease 
was essentially malignant from near the beginning. 

The duration of each of these forms varies very con- 
siderably in different cases. There is perhaps no other 
acute disease in which the period of convalescence is 
more variable and uncertain. The duration of the mild 
form may not exceed nine days, or it may be protracted 
to twenty, thirty, forty, and even to fifty days, in 
either event neither the patient nor his physician ob- 
serving any material change after the first twelve or 
twenty days, except that there has been a gradual de- 
crease of bodily strength; or the case thus mild for 
several days may pass into the intermediate form and 
yet not run a longer course, before the more aggravated 
symptoms pass off; or, after having completed a longer 
or shorter measure of the symptoms of this form, may 
still take on the severer class of symptoms belonging to 
the malignant, and yet the duration of this case may 
not exceed the limits of one of the mild form. But the 
malignant form of enteric fever, as I have before indi- 
cated, is not always the consequence of the existence 
first of the milder forms. In many instances the disease 
is essentially malignant in the beginning, or a few days 
thereafter, and in these also the duration is alike vari- 
able. These differences of duration will be more fully 
set forth in a subsequent chapter. 



CHAPTER II. 

SYMPTOMATOLOGY OF ENTERIC FEVER. 

Everything or circumstance happening in the body of a sick per- 
son, and capable of being perceived by himself or by others, which 
can be made to assist our judgment concerning the seat or the nature 
of his disease, its probable course and termination, or its proper 
treatment; every such thing or circumstance is a symptom. — Watson. 

PRODROMATA. 

The accession of enteric fever is quite different in 
different cases ; some come on suddenly without any pre- 
monitions. In others, the period of incubation is ex- 
tended from two to six days, and in a few instances, 
even to eight, ten, and twelve days; the patient com- 
plaining the mean while of sensations of mental and 
bodily languor; inability to perform his accustomed ex- 
ercise ; a dull, heavy pain in the head, back, and limbs, 
with a degree of muscular soreness, almost amounting to 
positive pain. At the same time, he experiences feel- 
ings of chilliness alternating with heat ; the appetite is 
greatly impaired ; occasional nausea ; some unnatural 
thirst, with a dry, insipid state of the mouth; the pulse 
grows quick, usually ninety to ninety-five per minute; 
the countenance expresses indifference; the sleep is in- 

2* (17) 



18 ENTERIC FEVER. 

terrupted, on account of an evening exacerbation of 
febrile excitement; and the morning arrives, bringing 
vrith it no marked alleviation of the symptoms. In 
some instances, however, there seems to be a morning 
remission of all the troublesome symptoms, and some- 
times free sweating occurs. Again, in a very few in- 
stances, I have seen this relaxation of symptoms occur 
on alternate mornings, and continue for several days 
after the disease was fully formed, though not so dis- 
tinctly marked as during the formative stage. There 
may be, at the same time, a moderate diarrhoea, or a 
costive state of the bowels, with now and then a few 
wandering pains in this region, with a sensation of more 
or less fullness of the stomach, the latter attracting the 
particular notice of the patient, who wonders why it is 
so, frequently remarking, that "for several days I have 
not been able to eat anything worth mentioning." 
Hour after hour these ill-feelings grow more distressing, 
when at last a sensation of chilliness, more severe and 
prolonged, is experienced, with an aggravation of the 
headache, backache, etc. The patient is now gladly in- 
duced to take his bed, although a few hours before he 
nattered himself that his feelings of malaise were only 
those resulting from the effects of a severe cold — too 
trifling to require medical aid — which would pass off of 
themselves. 

Such is the outline of the formative symptoms of en- 



MODE OF ACCESS. 19 

teric fever, in the maximum number of cases. In the 
minimum number this regular succession of prodromata 
is not observed: headache, backache, chills, sometimes 
nausea and vomiting, with more or less prostration of 
physical strength, seem to be the immediate accompani- 
ments of this mode of attack. 

The annexed table will show the mode of access in 
one hundred and thirty consecutive cases in my prac- 
tice, in which I endeavored to ascertain this point: — 

MALES. 

Access sudden in 19 cases. 

2 days formative stage in 9 " 

3 days formative stage in 24 " 

4 days formative stage in 11 " 

5 days formative stage in 4 " 

6 days formative stage in. 2 " 

8 days formative stage in 2 " 

71 " 

FEMALES. 

Access sudden in , 21 cases. 

2 days formative stage in 12 " 

3 days formative stage in 15 " 

4 days formative stage in 6 " 

5 days formative stage in 4 " 

6 days formative stage in " 

7 days formative stage in 1 case. 

59 cases. 
It will be seen that in those cases in which the access 
was sudden, and those on which the formative stage was 
lengthened to two days, a slight preponderance is exhi- 
bited in favor of females ; but those in which it was pro- 
tracted to three, four, five, and six days, form a majority 
in favor of males. 



20 ENTERIC FEVER. 



I.— SYMPTOMS OF THE MILD FORM. 

Of the one hundred and thirty cases spoken of, sixty- 
four were of the simple or mild form, the symptoms 
peculiar to which were as follows : a marked increase of 
the former symptoms; the pulse more frequent, say 
from ninety-five to one hundred; increased heat of skin; 
respiration a little hurried; urgent thirst, the patient 
calling for water every twenty or thirty minutes ; violent 
headache and throbbing of the temples; face flushed 
and apparently swollen; tongue covered with a white or 
yellowish fur, occasionally dotted with an aphthous exu- 
dation; urine diminished in quantity and highly co- 
lored; wandering pains in the stomach and bowels; 
nausea, and occasionally free vomiting ; entire disgust 
for food; bowels inclined to looseness, slightly tympani- 
tic, and a gurgling noise, with tenderness on pressure, 
over the coecal region. This gurgling noise I have 
found to be a constant accompaniment of enteric fever. 
The patient passes restless nights, his sleep is disturbed, 
and even rendered painful by frightful dreams, fre- 
quently crying aloud as if an actual participant in some 
fearful tragedy. During his dozing moments through 
the day, painful impressions trouble his mind. A com- 
mon impression is, that his body is severed in pieces, one 
portion at one side of the bed, another at the other, 
which he attempts to reunite, and at the point when he 



SYMPTOMS OF THE MILD FORM. 21 

is about to succeed in his imaginary undertaking, some 
other accident befalls him, when he suddenly awakes to 
communicate the torture of mind he has undergone. 

Toward the fifth day the headache generally passes 
off, but in its .stead, in many instances, increased ob- 
tuseness or drowsiness of manner is observed. During 
the progress of an ordinary case, the bowels are moved 
two or three times a day, the stools, in appearance, 
"resembling new cider;" there is a daily exacerbation 
of fever, most generally toward evening, sometimes 
twice a day, during which red spots about the size of a 
half-dollar occasionally appear, first upon one cheek and 
then the other, rarely upon both at the same time; or, 
in the absence of the spot on the cheek, the nose may 
become red and shining, giving to the patient rather a 
strange appearance; there may be also occasional epis- 
taxis, though seldom profuse ; the tongue, after the first 
four or five days begins to look red around the tip and 
edges ; sometimes it remains clean throughout, at other 
times it is thickly coated with a whitish or yellowish 
looking fur; sometimes it parts with its fur first in 
patches, one side clean and of a bright-red, while the 
other half is covered more or less thickly; it may be 
moist, and continue so during the entire course of the 
disease, but it is very frequently inclined to dryness, 
and when protruded will tremble. 

During the entire advance of the case, connected with 



22 ENTERIC FEVER. 

the above symptoms is more or less cough. It usually 
sets in after the close of the first four or five days, and 
may be very slight or troublesome, followed very often, 
toward the close of the disease, with free expectoration. 
After the disease has continued for several days, whether 
the diarrhoea be troublesome or not, there is invariably 
more or less tympanitis ; most generally it is slight. But 
among the number of symptoms enumerated, no one is 
usually so well marked and constant as debility, and the 
degree in which it exists, at any period, cannot be cor- 
rectly estimated, unless when the patient attempts to sit 
up, in or out of his bed : a soft couch and cool water are 
to him the greatest luxuries. 

To complete the description of the symptoms of this 
form, I mention another accompaniment, the rose-colored 
eruption, the regular appearance of which I have seldom 
failed to observe at some period of the disease. I can- 
not say this much of the transparent vesicular eruption 
called sudamina, never having noticed it but in a few 
cases, all of which occurred in the form next to be 
described. 

Delirium is not a constant symptom of the simple or 
mild form of enteric fever, though its occurrence on 
waking from sleep, or during the night, is not at all 
uncommon. The mind, however, always acts correctly 
when the attention is drawn to any particular person or 
subject. 



SYMPTOMS OF THF^ MILD FORM. 23 

I have thus attempted to describe the symptoms, with 
their modifications, peculiar to the mild form of enteric 
fever, all, or a majority of which, enter into the compo- 
sition of every case of the disease. The duration of 
these symptoms differs very considerably in different 
cases, yet the amelioration or aggravation of certain 
symptoms at certain times, either point to approaching 
convalescence, or portend the conversion of this form 
into one of greater severity. If the case is to assume a 
graver character, the symptoms above enumerated be- 
come sooner or later exasperated ; there is a greater 
diminution of the secretions ; the pulse becomes more 
frequent, and exhibits less strength ; greater obtuseness 
of the senses, with wandering of the mind during the 
day ; diarrhoea increased, etc. But if the case is about 
to terminate in convalescence from this form, then there 
is an entire relaxation of these symptoms ; the febrile 
exacerbations are less marked and of shorter duration ; 
the skin relaxed and perspiring; the sleep refreshing; 
the pulse becomes soft and less frequent ; the tongue, if 
it has been furred, loses its coating and is moist ; the 
stools less frequent, and of greater consistence; the 
quantity of urine voided is considerably augmented ; the 
abdomen becomes soft and loses its tympanitic sound 
when struck with the fingers ; thirst diminished ; the 
countenance brightens; the features shrink, and the 
appetite returns. 



24 ENTERIC FEVER. 



1 1.— T HE INTERMEDIATE FORM. 

Thirty-two cases presented the exasperation of symp- 
toms characteristic of this form, which was as follows : 
the febrile exacerbations became more prolonged, and 
their abatement followed less frequently with moisture 
of the skin; the pulse more frequent, say 110, 115, 
120, or 130 to the minute, and of less strength; greater 
dryness of the tongue, with an increase of coating. In 
this form, as the case advances, the condition of the 
tongue becomes peculiar ; its edges are thin and of a 
bright-red color, and apparently contracted, for its sur- 
face is concave, resembling slightly in form, the bowl of 
a spoon with its point bluntly rounded and cracked at 
the centre. Frequently there is a dark-brown stripe, 
from a half to three-fourths of an inch in width, running 
down the middle of the tongue as far back as can be 
seen ; and if the patient is told to show it, he does so 
with difficulty, but after a few trembling attempts he 
succeeds, the whole performance telling pretty plainly 
how much strength yet remains. There is also, at the 
same time, an accumulation of sordes about the angles 
of the lips, upon the gums and teeth ; twitching of the 
tendons ; increased somnolency ; duskiness of the counte- 
nance, and increased confusion of mind. The patient 
does not call so often for cool drinks ; he seems insen- 
sible, in a great measure, to his own wants. If there is 



TH& INTERMEDIATE FORM. 25 

a disposition to go to stool, he does not make his want 
known to the attendants until just at the time he feels 
that the discharge must take place, and he will suffer his 
bladder to become enormously distended, sometimes 
without an effort, or even a desire, to empty it. Dull- 
ness of hearing is a common attendant upon this form 
of the disease. In some instances it almost amounts to 
complete deafness. Wandering of the mind, more or 
less, is almost always present. It now occurs during 
the day, and sometimes very strange impressions trouble 
the mind. It is quite a common thing for patients to 
imagine the foot-posts of the bed converted into un- 
comely personages, placed there to make all sorts of 
grimaces, and they will frequently start up in anger to 
drive them from the room, the effect of which, for the 
time, dispels the illusion, and they lie down wondering 
at themselves for being so grossly mistaken. Soon, 
however, this Quixotic sally is repeated, and thus the 
patient is constantly annoyed, except when the attention 
is rationally fixed. During the night the delirium be- 
comes more constant, though in these cases never so 
profound but that the presence of the physician, or some 
strange visitor, causes the mind to act correctly. 

Coincident with the above there are other and signifi- 
cant symptoms having peculiar reference to the state of 
the bowels. Upon an examination of the abdomen a 
marked increase of tympanitic distension will be ob- 

3 



26 ENTERIC FEVER. 

served. Diarrhoea is more or less present, always pro- 
portioning the amount of meteorism to the frequency of 
the discharges. It is sometimes slight, causing not 
more than two or three stools in the course of a day, 
and at others, as many as ten or twelve in as many 
hours. The dejections, for the most part, are darker 
and more offensive than in the mild form, and some- 
times attended with very acute pain, which is most 
generally referred to the umbilicus. The urine is deeply 
colored, passed in less quantities, and occasionally with 
much difficulty. When there is a disposition on the 
part of the patient to empty his bladder, he cannot 
always succeed in his effort, and unless relieved by the 
catheter much suffering is the consequence. It is in 
the region of the bowels that the rose-colored spots 
generally first make their appearance; sometimes they 
are but few in number, at other times spreading over 
the entire breast and shoulders. Upon an average, I 
have not found this eruption to occupy as much surface 
as in the preceding form. Sudamina, as before ob- 
served, I have not so often noticed, but whenever found 
was always in this form of the disease, preceded for a 
day or two, at intervals, by free perspiration. Epis- 
taxis, when it occurred, was always more profuse than 
in the milder form. In three cases the loss of blood in 
this way was extensive, and for several days obstinately 
resisted all attempts to arrest it. Two of these patients 



THE INTERMEDIATE FORM. 27 

recovered. This form of the disease may go on unde- 
termined for a few days only, or for many days, flat- 
tering us at one time with an approach of convales- 
cence, at another exciting our fears. It is not at 
all uncommon to see the tongue clean, become moist, 
the countenance brighten, diarrhoea and tympanitis 
diminish, and the skin become moist, when, without the 
slightest apparent cause, there is a sudden and alarming 
aggravation of all the symptoms ; the tongue, just rid of 
its coating, becomes dry, red, cracked, and bleeding; 
fresh sordes accumulate on the lips and teeth; frequent 
disposition to stool — at one time a free passage, dark 
and offensive, at another small, with a corresponding 
increase of tympanitis and abdominal tenderness ; pulse 
more frequent and less resisting ; previous duskiness of 
the countenance, and delirium ; twitching of the ten- 
dons, and the skin hot and dry as before. This muta- 
tion of symptoms may last but a day or two, and the 
patient recover without necessarily taking on the graver 
symptoms reserved as peculiar to the next and gravest 
form, the malignant. When the case is to convalesce 
from this form, this aggravation of symptoms just 
named as rapidly subsides ; the tongue coats over again 
with a thin white fur, and is moist, and the state of the 
pulse, the bowels, and the mind, become as favorable as 
before, and the case gradually merges into convales- 
cence. 



28 ENTERIC FEVER. 



III. — THE MALIGNANT FORM. 



I have already said that enteric fever may be stamped 
with malignancy from the beginning, without having ne- 
cessarily to pass through the milder gradations. This, 
however, is not generally the case. The majority of 
cases of this form is preceded, for a longer or shorter 
period, by each of the simpler forms. Twenty-five cases 
passing through the milder gradations, resulted in this 
form. To describe the symptoms peculiar to these, I 
shall go back to the point at which I left off, as com- 
pleting the description of the intermediate form, and 
endeavor to present a continuous picture of the disease, 
from the mildest to the most severe, and then proceed 
to notice the rapid succession of symptoms occasionally 
occurring, which mark the case as malignant in the be- 
ginning. 

As already stated, it is not uncommon, after a seem- 
ing amelioration of all the symptoms, for sudden and 
alarming changes to occur, exposing the patient to the 
dangers of a still severer form, the most remarkable of 
which was the drying of the tongue after having become 
clean and moist. When the disease is to assume greater 
gravity, it is generally at this juncture that it becomes 
apparent; and the case, thus aggravated, more or less 
rapidly proceeds to a final termination, either in re- 
covery or death. Prominent, amid this increase of 



THE MALIGNANT FORM. 29 

number and severity of symptoms, will be a marked 
prostration of strength. The patient does not usually 
lie upon bis side, but on the back, with a disposition to 
slip down in the bed. The pulse becomes more frequent 
and feeble ; in some cases it is almost impossible to 
count it, on account of the constant twitchings of the 
tendons of the wrists — subsultus tendinum. In a few 
cases these muscular twitchings amount to a general 
tremor, and in such instances even the bedclothes are 
in constant movement — or if one lean upon the bed- 
stead, a trembling sensation is distinctly perceived. The 
tongue takes on an additional coating — is black, and 
bloody crusts form about the mouth. If the patient is 
requested to protrude his tongue, he may do so, but the 
movement is slow and trembling, and he will likely leave 
it exposed if not told to take it in. In many cases 
deglutition is interfered with, so that it is with great 
difficulty that food and drinks are introduced into the 
stomach. The voice is sensibly altered. In some cases 
it becomes so feeble that the patient cannot be heard 
above a whisper; at other times it may be strong 
enough, but the articulation is so imperfect that all 
attempts at conversation amount only to a trembling 
jargon. Cough is more or less present; expectoration 
sometimes free, at other times nothing but a little frothy 
mucus is expelled; the breathing is usually somewhat 
hurried, and occasionally it becomes irregular. The 

3* 



30 ENTERIC FEVER. 

heat of the surface may be uniform, or it may be un- 
equally distributed, — one part hot and parched, while 
another is cool, or the face and hands may sweat freely, 
while the rest of the body is dry and husky. If, at the 
same time, attention is paid to the state of the bowels, 
a proportionate degree of disorganization will be found 
to have taken place there : the tympanitic distention has 
enormously increased, so as to present sometimes "a 
convex outline from the ensiform cartilage to the pubis;" 
and if pressure is made, the entire abdominal surface 
appears thin, hard, and resisting, "as though its walls 
were made of pasteboard;" and scattered here and 
there upon its surface will be found, perhaps, a few of 
the rose-colored spots. The stools are more or less fre- 
quent, very offensive, and in color and consistence may 
resemble brown paint, or even tar, and the coating which 
these discharges give to the pot is not always easily re- 
moved. It is in this form of the disease always that 
the most frequent and profuse hemorrhages are ob- 
served. In some instances the blood discharged from 
the bowels is red and but little changed; in others it is 
dark and disintegrated. The urinary discharge has also 
undergone a commensurate degree of alteration. While 
the quantity of urine voided at a time has become less, 
its color is that of dark lye, and not unfrequently little 
particles of coagulated blood are deposited at the bot- 
tom, on suffering it to stand awhile ; or it may be re- 



THE MALIGNANT FORM. 31 

tained, requiring the repeated use of the catheter. 
Delirium is a common attendant upon this form of the 
disease. It may be attended with wild and violent agi- 
tation, but more frequently is of that species called low 
and muttering ; the patient picks at the bedclothes, or 
at imaginary objects. Soon succeeds involuntary dis- 
charges of urine and faeces, and there arises from the 
patient's body the most sickening odor. Along with 
the above symptoms, the vitality of the skin becomes 
so feeble that the parts exposed to pressure, as the sa- 
crum, hips, and shoulders, become abraded — which are 
most likely to be followed by sloughing. 

Finally, if after a long and tedious struggle between 
the efforts of nature to cure, and the powers of disease 
to kill, nature is about to triumph, the pulse becomes 
less frequent and acquires strength; the delirium and 
stupor gradually subside; suhsultus tendinum ceases; 
the tongue becomes moist and cleans from the tip and 
edges ; the discharges from the bowels are less frequent, 
less offensive, of brighter color, and more consistent; 
the quantity of urine discharged is increased and it 
lightens in color, and on standing throws down a thick 
sediment; the skin becomes moist and of uniform 
temperature; the features shrink, the eye brightens, 
and the appetite returns. But if disease gain the mas- 
tery, it may accomplish its purpose of death in different 
ways. If it is to be by coma, the low muttering deli- 



32 ENTEEIC FEVEE. 

rium, from which the patient could at first be aroused, 
gradually becomes more profound; petechia and vibices 
make their appearance upon the surface; swelling and 
ulceration of the parotids not unfrequently occur; the 
jaw falls by its own weight, and the lips tremble conti- 
nually; the patient lies with half-closed eye-lids, and 
the balls are seen to roll from side to side; the pulse 
beats so rapidly that it can scarcely be numbered, and 
with decreasing regularity and strength ; the respiration 
is rapid and irregular; automatic efforts are made to 
expel the mucus which chokes up the lungs and begins 
to rattle in the throat ; a cold, clammy sweat breaks out 
upon the skin; the extremities become cold, this cold- 
ness gradually extends to the trunk, when, at last, there 
is a final struggle and death reigns ! 

In other instances death approaches by almost imper- 
ceptible degress : the patient, with perfect consciousness, 
passes quietly away, bearing the happy testimony that 
the exit of life is more terrible to the spectators than to 
him whose frail bark is being launched upon the dismal 
stream. The tendency to this or that mode of death 
will be more fully spoken of in a subsequent chapter. 

I have now completed the symptoms of a case of en- 
teric fever, either mild throughout, or after having 
been mild for a longer or shorter time, passing into the 
intermediate form, and convalescing from this, or enter- 
ing into one of still greater severity — the malignant 
form. 



THE MALIGNANT FORM. 33 

I now come to speak of those cases, occasionally oc- 
curring, in which a degree of malignancy is observed in 
the beginning or very soon thereafter. Nine cases as- 
sumed this cast immediately upon the lull development 
of the fever. These patients were not all suddenly 
taken down: six of them complained of feeling unwell 
for three days previous to taking their beds; the re- 
maining three retired to bed at night, enjoying their 
usual health, and awoke in the morning with sickness 
and vomiting, headache, etc., soon followed by a chill 
and then high fever, etc. In all of these cases strong 
manifestations of cerebral disorder were present at the 
development of the disease: aversion to light and 
sound, watchfulness, succeeded by confusion of mind 
and delirium, the latter coming on during the first two 
or three days of the disease. During the farther ad- 
vance of the case, the delirium became continuous, and 
occasionally violent ; the eyes injected; the countenance 
of a dusky hue; startings of the tendons; skin in- 
tensely hot ; the bowels, at first, a little inclined to be 
sluggish; the tongue thickly coated, of a dark color, 
and inclined to dryness ; pulse 115, 120 or 130, and not 
very firm ; cough and hurried respiration ; bleeding at 
the nose, which was sometimes free, and with difficulty 
arrested; the urine diminished in quantity and highly 
colored. Such were the symptoms attending these 
cases for the space of six or seven days, after which, 



34 ENTERIC FEVER. 

instead of the previous sluggishness of the bowels, diar- 
rhoea set in, with thin, curdy-looking discharges, and 
accompanied with tympanitis, and a marked prostration 
of strength. The pulse after this time was of less 
strength ; heavier sordes formed about the lips, gums, 
and teeth ; the tongue very dry, and its coat looking as 
though it were made of black varnish, for it glistened; 
and when protruded trembled exceedingly. The case 
thus far described may go on undetermined for only a 
few days longer, or even for weeks. When it is to re- 
sult fatally, the case takes on the additional symp- 
toms tending to death by coma, as already enumerated. 
Two of these cases only terminated fatally. 



CHAPTER III. 

RECAPITULATION OF SYMPTOMS. 

The importance of carefully studying the symptoms 
of enteric fever cannot be over-estimated. From the 
symptoms we form our diagnosis and prognosis, and 
learn the proper direction to conduct the treatment. 

From the description given in the previous chapter, it 
is seen that there are certain symptoms belonging to 
the disease which are of especial importance, both as 
regards their constancy and their relation to the diag- 
nosis and prognosis of the affection. These I shall 
notice as follows : — 

1. Headache. 

2. State of the Mind and Senses. 

3. State of the Muscles. 

4. State of the Pulse. 

5. Cough and Bronchial Rales. 

6. Diarrhcea. 

7. Tympanitis. 

8. The Rose-colored Eruption. 

9. Hemorrhage. 

10. Tendency to the Formation of Eschars. 

(35) 



ob EX TEE IC FEVER. 

1. Headache. — Headache, with a sense of heaviness 
and vertigo, is very seldom absent at the beginning, and 
in many instances is the only subject of complaint 
throughout the entire course of the disease. In 128 of 
the 130 patients who were of sufficient age to express 
suffering, headache was complained of in all save one. 
This patient suffered from the mild form of the disease. 
It is most generally described as being confined to the 
forehead and temples, but sometimes to the back of the 
head and neck, and at other times the head is said to 
ache all over. Along with this pain, whether confined 
to the frontal or occipital region, there is usually more 
or less tenderness of the entire scalp. The character 
and degree of this pain are various. Generally it is de- 
scribed as a dull, heavy, throbbing pain. Sometimes it 
is excruciatingly severe, and now and then I have seen 
it assume a neuralgic character. This was the case 
with a patient, a female, included in the cases of the in- 
termediate form. The duration of this pain varies. It 
may continue for three or four days only, or last until 
the beginning of convalescence. Its average duration, 
in the mild form, I think may be estimated at about six 
days. In those cases which pass into the severer form, 
the intermediate, it is usually of longer duration, and, 
perhaps, of a more acute character. 

Relief from this suffering does not come suddenly. 
In the milder form its gradual cessation may be said to 



STATE OF THE MIND AND SENSES. 37 

occupy some two or three days. In the severer forms 
it is generally lost in delirium and stupor. 

2. State of the Mind and Senses. — One of the 
earliest and most constant phenomena incident to 
enteric fever is a marked alteration in the activity of 
the mind. There is a blank, apathetic, or dejected ex- 
pression of the countenance, which is so indicative of 
cerebral disorder that we have but to look on our 
patient to know that he is mentally indisposed. He is 
forgetful, and finds it difficult to fix his mind upon any 
one subject. He is indifferent to all occurrences that 
take place around him, for the prosperity of his busi- 
ness, however actively it was his custom to be engaged 
prior to taking his bed. Sometimes, however, instead 
of this listlessness and indifference of manner, the idea 
of his compulsory pause in business torments him, and 
he becomes restless, impatient, irritable, childlike, and 
manifests an interest not only in his business concerns, 
but the greatest solicitude for his recovery. He waits 
with impatience the promised visits of his physician, 
whom he charges with gross negligence if from any 
cause an expected visit has been for a few hours de- 
layed. This supposed negligence, however, is soon 
atoned for by the physician's presence, and favorable 
answers to the interrogatories, " How do you think I 

4 



38 ENTERIC FEVER. 

am to-day, doctor?" "How long will it be, do you think, 
before I shall begin to mend?" 

Either of these conditions of mind, in the mild form, 
may continue up to the period of convalescence. In 
the graver forms they are sooner or later lost in delirium 
and stupor. 

Delirium is a common accompaniment of the disease. 
It may be either calm or violent. In the mild form the 
mind wanders only at night, or when the patient is left 
to himself; but in the succeeding form this wandering 
occurs during the day, when the attention is not directly 
fixed. It is generally the case that the mind can be 
influenced to act correctly and to fix itself, when en- 
deavors to this end are made by the physician or at- 
tendants ; and it is rare to find a patient, at any stage 
of the disease, who does not retain a partial con- 
sciousness of his situation. He may keep up a constant 
muttering of incoherent sentences, yet if spoken to in a 
commanding tone pays a partially intelligent attention ; 
or if opposed in his attempt to commit any impropriety, 
will offer no resistance. When the delirium is violent 
it usually requires constant restraint to keep the patient 
in bed. He cries, laughs, and makes use sometimes of 
the most obscene language. At other times he seems 
in a fit of anger, and in some imaginary rencounter, 
strikes at the bed-posts, the wall, or at the attendants, 
with all his strength; his consciousness being embar- 



DELIRIUM. 39 

rassed " by false presentations, illusions, phantasms ; a 
condition in which he is haunted by spectra analogous 
to those visual and auditory sensations which arise in 
connection with disease in the optic or acoustic nerve; 
a state in which the centre of consciousness, abnormally 
excited, forges subjectively all manner of images of in- 
cident and circumstance, with a self-assurance of their 
objective reality."* A very common impression with 
such patients is, that they are absent from home, and 
surrounded by persons who take particular delight in 
doing them an injury to both person and property; and, 
harassed by these impressions, they leap out of bed, 
and if not at once arrested, make for the door, or in the 
attempt, fall exhausted upon the floor. 

In a few instances the delirium is strictly mono- 
maniacal. Thus a patient, aged thirty-six, included 
among the number of intermediate cases, had the im- 
pression that God had communicated to her His decree 
of her death, and the precise day on which she would 
die ; that her sins were such as could not be forgiven, 
and therefore she was to be eternally lost ! She indig- 
nantly spurned the idea of successful medical treatment, 
and even declared my presence presumptuous. My 
approaches to her bedside she endeavored to repulse by 
the interrogatory, "Do you think, sir, yourself greater 

* Simon's Genl. Pathology, p. 153. 



40 ENTERIC FEVER. 

than God? He has decreed my death to take place 
next week, and it will take place at that time in spite of 
all earthly interposition." For several days she con- 
tinued in this state of mind, yet finally recovered with- 
out anything further strange connected with her case. 

The species of delirium most frequently observed in the 
severest form of the disease, is that denominated low and 
muttering, and succeeds the milder degrees of suspended 
consciousness. The patient lies with half-closed eyes, 
and utters in a low and whispering voice disjointed sen- 
tences, having only a vague connection. Sometimes he 
is in constant motion, picking at the bedclothes, throw- 
ing them about, or drawing them tightly over his head. 
In the majority of such cases profound coma soon 
succeeds, from which no stimulus can arouse the patient. 

The frequency and degree of delirium are in pro- 
portion to the severity of the disease. When it ap- 
pears early, and is well marked, the case is sure to run 
a grave course. In the majority of cases it does not 
usually make its appearance in a well-marked form 
until during the second week. 

It is equally common among children, who suffer from 
the disease. Its character, however, is usually mild, 
and shows itself earlier than in adults. Of twenty- 
seven cases of the malignant form, terminating in re- 
covery, delirium was well marked in twenty-five. Of 
eleven fatal cases, this symptom was present in a de- 



DELIRIUM. 41 

cided form in ten, the exceptional case passing into 
death without a cloud to obscure its approach. 

From the above it will be perceived that the symp- 
toms relating to the state of the mind may vary from 
mere mental languor or inactivity, in the beginning, to 
the wildest delirium; that the embarrassment of con- 
sciousness may cease here, or be extended to carus, a 
state of complete insensibility, the last step in the 
march to death. The presence of this symptom is 
sometimes of long duration. I have known patients suf- 
fering from enteric fever who continued in a state of 
delirium for upwards of twenty days ; but this is not 
common. Its subsidence or diminution constitutes the 
surest sign of approaching convalescence. 

It is worthy of remark here that while it is usual for 

the mind to have regained its entire soundness by the 

time convalescence is fairly begun, that occasionally 

cases occur in which a morbid condition shows itself 

even after the patient is able to be out of doors. A 

case of this kind is included among the nine cases 

spoken of, presenting a severe form of the disease in 

the beginning. The case was that of a young man aged 

eighteen, of robust form, business that of clerk in a dry 

goods house, and of an active turn of mind, who, after 

complaining of the usual prodromata for a few days, was 

taken down, and suffered a rapid succession of grave 

symptoms. Delirium came on early, and after the first 

4* 



42 ENTERIC FEVER. 

five days was attended with wild and violent agitation 
to such a degree as to require the constant attention of 
his friends to keep him in bed. At the end of twenty- 
one days the delirium had entirely subsided, and he be- 
gan to relish a little food, and by the thirty-second day 
he could be out of doors. From the time the delirium 
passed off up to this last-named date, he had not ex- 
hibited the slightest aberration of mind ; but, very much 
to the surprise of his friends, on the next day, the 
thirty-third, he accused the servant-girl of having stolen 
his account-book, "with a leather back," in which, he 
said, he had charged several of his friends with large 
sums of money loaned, money that he had drawn in lot- 
tery, amounting in all to §10,000. His mother, who 
was present at the time, endeavored to convince him 
that he was wholly mistaken ; that he had certainly not 
been so fortunate as to gain money in that way, and 
that he was troubling himself about a matter altogether 
imaginary. At this he became angry, declaring most 
solemnly that his whole statement was true ; that he 
had had the money in his own hands, charged the 
amounts loaned in the aforesaid book ; that he was not 
mistaken, and accused her of having joined in with 
other of his debtors to defraud him of the whole sum. 
In a few days, however, he became convinced of his 
error, and could laugh over it heartily. 

One other point concerning delirium I mention. 



DULLNESS OF HEARING. 43 

Among the educated classes, delirium is more frequent, 
and is usually more strongly marked than among the 
uneducated. My attention has frequently been called 
to this fact. Dr. Stokes mentions the same thing. 

Dullness of hearing is one of the most constant altera- 
tions in the functions of the senses observed in 
enteric fever. It is usually preceded by dizziness and 
ringing noises in the ears, the latter sensation coming 
on when the patient attempts the upright posture. The 
sense of hearing, in some instances, is so materially 
altered as to amount almost to entire deafness. This 
was the case with a patient, a female, who suffered from 
the intermediate form of the disease. In order that she 
should hear me in conversation I had to speak at the 
top of my voice. This symptom is equally common in 
the mild as in the severer forms of the disease, but the 
degree to which it exists is not so great, usually, in the 
former as in the latter. In the severer forms the hear- 
ing is sometimes false, as when the patient answers to 
some imaginary interrogatory. Entirely to the con- 
verse of dullness, this sense sometimes becomes mor- 
bidly acute ; the slightest noise, as the jar of the floor 
produced by walking across it, attracts the attention, 
and unless perfect stillness reigns about the room the 
discomfort of the patient is greatly increased. This 
occurred with a majority of the cases which terminated 
fatally. 



44 EXT ERIC FEVER. 

In grave cases the sense of vision is more or less per- 
verted. This accompanies that hypersesthetic condi- 
tion of the centre of consciousness heretofore spoken of. 
The patient sees the foot-posts of his bed, or any other 
object within his field of vision, not as they really are, 
but transformed into all sorts of things. 

The expression of the eyes varies with the gravity of 
the disease. In mild cases the eyes are suffused and 
dull, or swimming and fatuous, as in incipient inebriety. 
In graver cases, especially in those which assume this 
character at an early stage, they are bright and 
shining, with increased sensibility to light, and soon 
follow injection and redness of the conjunctiva. At an 
advanced stage of the disease the eyelids move feebly ; 
spasm of the levators occurs, and the patient lies with 
half-closed lids. Upon the approach of death the cor- 
nea sometimes becomes clouded, and often flakes of 
mucus obscure its surface. 

3. Prostration of Muscular Strength. — Prostration 
of muscular strength stands prominent among the most 
constant phenomena of enteric fever. It has been 
already remarked that even in the mildest cases of the 
disease loss of strength is among the first subjects of 
complaint. During the formative stage, and before the 
patient takes to his bed, his gait is tottering, and if he 
attempt to perform any manual labor he finds himself 



PROSTRATION OF STRENGTH. 45 

soon fatigued. Dr. W. W. Parker, of Richmond, Ya., in 
a letter to me, dated November 24th, 1858, among other 
things, says : "This unnatural debility is one, if not the 
most, characteristic symptom in mild cases — indeed, it 
seems often to be the only symptom." The description 
given by Dr. Bartlett, of the state of the strength, can- 
not be improved. He says: "A great majority of 
patients take to their beds at the beginning of the dis- 
ease, and remain there almost constantly until the com- 
mencement of convalescence. They will suffer them- 
selves to be placed passively in a chair, in order that 
their beds may be made up and aired, but they are im- 
patient and anxious to be returned as quickly as pos- 
sible. When this prostration is extreme, unless there 
are great restlessness and distress, or delirium, the 
patient lies constantly in the same position on his back, 
entirely passive, with hardly sufficient strength to move 
his limbs. It is necessary for his attendants to raise 
him up in bed, and to hold to his lips the cup when he 
drinks. Conversation addressed to him is irksome and 
fatiguing, and he answers questions with reluctance, 
and with a painful effort of his exhausted strength."* 

The frequency of spasmodic action of the muscles 
occurring in the disease, will excuse further remark 
concerning it. When this symptom shows itself in a 
well-marked form, I have invariably found the case one 

* Treatise on Fevers, p. 51. 



46 ENTERIC FEVER. 

of great gravity. In mild cases it is only indicated by 
a tremulous movement in performing any voluntary act, 
caused by the irregular action of the muscles employed 
in its performance, and differing in some measure from 
the tremor of mere weakness by this irregularity. In 
the intermediate form it is more constant. In the 
gravest cases it is combined with delirium, assuming the 
character of floccitatio — a picking at the bedclothes, 
performed in this tremulous and irregular manner.* 
This spasmodic action is not always confined to the 
muscles of the arm ; it frequently extends to the legs 
and other parts of the body; there may be hiccough, 
twitchings of the muscles of the face, etc. I have seen 
the jaw in constant motion. Sometimes the patient is 
all over in a tremor, along with which condition his 
strength is so exhausted that he inclines to slip down 
in the bed, knees drawn up, and inclined to one side, 
and, when delirium is present, with the hands resting 
upon the genitals. Permanent rigidity of the muscles 
of the arm is a fearful symptom. 

From the beginning to the close of the disease there 
is generally a gradual increase of muscular disorder. 
In those cases of raving delirium, the patient will some- 
times, even during the third week of the fever, exhibit 
an astonishing degree of strength on being opposed in 
his attempts to commit any impropriety — for instance, 

* Barclay's Med. Diagnosis. 



STATE OF THE PULSE. 47 

to get out of bed. An increase of strength is the sure 
harbinger of returning health. This increase is gene- 
rally first shown in grave cases by the patient being 
able to change his position from lying on his back to 
his side; next he manifests a disposition to be propped 
up in bed; then to get out of the bed; and at each suc- 
cessive attempt is disposed to prolong the time of sit- 
ting, until he has accomplished a wliole day out of bed. 
It is indeed amusing sometimes to see with what pre- 
cision patients measure their return to strength. 

4. State of the Pulse. — The change of pulse most 
frequently observed, is that of frequency combined with 
weakness, and this change is in nearly exact proportion 
to the severity of the disease. In the mild form it 
rarely exceeds 115, and in quite a number of in- 
stances falls far short of these figures, and in a very 
few instances it falls below the natural standard. Dr. 
Parker, of whom mention was made on a preceding 
page, mentions an instance of this kind which fell under 
his observation. In mild cases it may be said to range 
between 90 and 110. It may be full and strong, but 
this is not commonly the case even during the earlier 
stages, weakness, with frequency, being the almost uni- 
form condition. In the severer form, the intermediate, 
it is not only marked by increased frequency, but it 
sustains a proportionate loss of strength. The pulse 



48 ENTERIC FEVER. 

in this form runs between 110 and 135, the last-men- 
tioned figures always standing as a strong probability 
that the case will pass into the third and gravest form 
of the disease. When the case takes on the character 
of greater malignancy, there may still be a more fre- 
quent pulse ; but in those cases which end in recovery, 
the proportion of increase is considerably less than is 
observed in fatal cases. In the worst class of cases it 
is quite common to find a pulse of 140, and even in 
some cases which recover, it counts as high as 160. 
Recovery, however, after a pulse of 160, is rare. In 
fatal cases, for a day or two before death, it sometimes 
runs so rapidly that it cannot be counted. Along with 
its frequency in the severer forms of the disease, it 
sometimes becomes so weak and small that it requires 
considerable delicacy of touch to detect it, and this 
difficulty is greatly enhanced if subsultus is present. 
In cases which exhibit a grave form of the disease in 
the beginning, the pulse may at first show, along with 
its frequency, considerable strength. But this strength 
is not permanent; in the course of a few hours some- 
times, it becomes small and weak. In the choice of 
blood-letting this fact is of the greatest importance to 
be remembered. 

5. Cough and Bronchial Rales. — Cough, more or 
less, almost invariably attends the disease. It may 



COUGH AND BRONCHIAL RALES. 49 

exist in the beginning, or not make its appearance until 
the latter part of the second week ; most generally it 
sets in during the first week. Its degree of severity 
is influenced a good deal according to the previous ex- 
posure of the patient, and the season of the year he 
is attacked. Cases occurring during the winter and 
spring months generally present this symptom in a 
well-marked form. At first, and in the mild form of 
the disease, the sputa are small, tenacious, and color- 
less ; but in the severer forms, or at an advanced stage 
of the disease, they are sometimes streaked with blood. 
This is most apt to be the case on clearing the throat 
in the morning, and especially if there has been epis- 
taxis. It sometimes becomes rusty from a complica- 
tion of pneumonitis. 

The physical signs connected with the respiratory 
organs, characteristic of the disease, consist in a rhon- 
chus, dry, sonorous, or sibilant, and which may be 
heard more or less extensively over the thorax. These 
rales are out of all proportion to the existing amount 
of oppression or dyspnoea, when compared with the aus- 
cultatory sounds heard in ordinary catarrhal affections, 
and hence the importance of the sign.* As was said of 
the cough, these signs sometimes follow close upon the 
accession of the disease, but in the majority of cases 
not until the disease is fully formed and continued for 

* Bartlett's Treatise on Fevers, p. 45. 

5 



50 ENTERIC FEVER. 

a few days. In the graver forms of the disease, 
and when the cough is attended with a rusty-colored 
sputa, they give place to crepitous rhonchus, the sign 
of secondary inflammation in the parenchyma of the 
lungs, a complication full of danger to the life of the 
patient. 

6. Diarrhoea. — If to constitute a diarrhoea simply 
requires the existence of a liquid state of the stools, 
then I have witnessed but two cases of enteric fever in 
which this symptom was not more or less present at 
some time or other, in the progress of the disease, and 
even in these exceptional cases the stools presented less 
consistency than is ordinarily observed in health. But 
this is not all that is necessary, in my use of the term, 
to constitute a diarrhoea, and unless along with the 
liquid discharges is added some unnatural frequency of 
peristaltic action, I do not so consider it. I mention 
this not because it is important that I should give a de- 
finition of diarrhoea, but simply that I desire to be cor- 
rectly understood in the description of this symptom 
given in the previous chapter. When I have said that 
there may be either costiveness or diarrhoea, I mean 
simply by the former that the dejections may be less 
frequent than in health; and by the latter, that they 
may become more frequent. When I have said that 
the bowels may be sluggish, I mean that the discharges 



DIARRHCEA. 51 

may not be wanting in natural frequency, but that there 
is a diminution in the quantity of fgeces discharged at a 
time. With this explanation I proceed to complete the 
description of this symptom. 

There is perhaps no one symptom belonging to en- 
teric fever which, according to the degree of its mani- 
festation, is so well proportioned to the gravity of the 
disease as diarrhoea. Even when it does not exist 
among the prodromata, the bowels show an increased 
susceptibility to the action of cathartic medicine, and 
by the exhibition of such medicine to purge off the sup- 
posed bad cold, the irritability of the bowels is in- 
creased, and diarrhoea brought on much earlier per- 
haps than it would have naturally occurred. In many 
instances, however, the discharges are liquid and fre- 
quent in the beginning, without any assignable cause, 
and in such cases the disease soon assumes a grave 
form. In mild cases it is not usual for diarrhoea to be- 
come troublesome. Sometimes the patient will have a 
discharge regularly every day, and this regularity will 
continue throughout the entire progress of the disease. 
In other instances in the same class of cases, the num- 
ber of stools will amount to two, three, or four, in the 
same space of time. In some instances the patient will 
have three or four discharges following each other in 
rapid succession, perhaps all in the space of an hour ; 
after which he is not troubled again for many hours, 



52 ENTERIC FEVER. 

and may be the bowels are not moved again until acted 
on by medicine given for that purpose. I have ob- 
served this tumultuous action of the bowels to occur 
more frequently in grave than in mild cases. Some- 
times there is a degree of pain attending each effort 
at stool, and in some cases it precedes the discharge 
for an hour or two. Occasionally it becomes very 
severe, and is most often referred to the navel and 
right iliac quarter. Deep firm pressure is not well 
borne when made upon this region, and when made, 
almost always produces a gurgling noise. I have spoken 
sufficiently of this gurgling noise on pressure over the 
ccecal region. The color of the discharges requires 
some remark. It is natural enough in the beginning, 
but on account of the loss of consistence the stools 
bear no resemblance to healthy ones. They have 
been aptly compared to new cider containing particles 
of the pomace. In the intermediate form of the dis- 
ease, they are usually darker and more offensive. Pain 
of the bowels, in this form of the disease, is more fre- 
quently present, but is not complained of generally 
until the patient is just in the act of having a dis- 
charge. 

In a very few cases I have known the discharges 
assume a dysenteric character, and which were ac- 
companied with almost constant tenesmus. In the 
malignant form there is generally urgent diarrhoea. 



TYMPANITES. 53 

The discharges present a dark and grumous aspect, 
sometimes resembling plum- juice, very offensive, and 
passed in considerable quantities. At other times they 
are red, from an admixture with blood ; and at other 
times resemble black paint, both as regards color and 
consistence. In one or two instances I have seen the 
very thin ochry-colored discharges continue to the close 
of the disease. In a fatal case, a boy aged eleven, 
the discharges, forty hours before death, resembled in 
color and consistence Indian-meal mush. Profuse he- 
morrhage from the bowels took place eight hours before 
death. 

In those cases denominated as grave in the begin- 
ning, there is generally but little, if any, increase of 
frequency to stool above that observed in health, during 
the first week of the disease, yet there is the same sus- 
ceptibility to the action of purgative medicine which 
exists in the other classes of cases. During the second 
week the condition of the bowels, as regards diarrhoea, 
is the same as in those cases gradually assuming a 
malignant character. 

Along with the diarrhoea of either form, strangury 
sometimes occurs, and when it exists, is particularly 
complained of when the patient is at stool, 

7. Tympanites. — Among the earliest symptoms of 
enteric fever is tympanites. It has been said already, 

5* 



0-4: ENTERIC FEVER. 

that even during the formative stage, a sense of full- 
ness of the stomach and bowels is complained of. 
This results from tympanites, for when the abdomen 
is percussed the characteristic sound is heard. The de- 
gree of its manifestation is generally proportioned to 
the amount of existing tenderness on pressure over the 
abdomen, and the frequency of the discharges, though 
I have observed it well marked in a few cases in which 
there was no appreciable tenderness, and that required 
medicines to act on the bowels; and in two instances 
have seen obstinate diarrhoea, with considerable tender- 
ness on pressure, which were not accompanied with any 
increase of this symptom beyond that ordinarily ob- 
served in the mildest cases of the disease. The transi- 
tion from the mild into the intermediate form, is most 
always attended with a marked increase t>f tympanites, 
and if the case still advance in gravity, the distention 
sometimes becomes enormous, and may materially inter- 
fere with respiration. In one fatal case a tympanitic 
sound could be produced from the pubis to the top of 
the sternum. 

This symptom generally continues until the beginning 
of convalescence, or the termination in death. In a 
few cases I have seen it diminish to a marked degree, 
without the slightest abatement of other symptoms. 
In a fatal case, aged eighteen, eight days before death, 
this symptom, after having existed for many days, and 



ROSE-COLORED ERUPTION. 55 

to a very considerable degree, suddenly lessened, and, 
at the end of the succeeding twenty-four hours, had 
almost disappeared; it soon reappeared, and continued 
to increase as the disease advanced to death. 

8. Mose-colored ^Eruption. — The frequency of ap- 
pearance, if not to say constancy of this eruption, has 
been remarked by all who have written concerning en- 
teric fever. In my experience I have seldom failed to 
observe it at some stage of the disease. It has been 
graphically described by Professor Wood, in his work 
on Practice. He says: "This," the eruption, "con- 
sists of small red spots, usually roundish, and about a 
line in diameter, though sometimes much larger, often 
slightly prominent, and disappearing under pressure 
with the finger, to return upon the removal of the pres- 
sure. They are never seen at the commencement of the 
disease, but generally first make their appearance be- 
tween the seventh and fifteenth day, and occasionally 
later." Their number, I think, is diminished in pro- 
portion to the extent of intestinal alteration. In mild 
cases of the disease, in which the diarrhoea is not trou- 
blesome, I have several times seen the patient spotted 
from head to foot. At other times the eruption was 
principally confined to the abdomen, chest, and inner 
part of the thighs. In other instances it was scattered 
upon the extremities, even to the fingers and toes, 



56 ENTERIC FEVER. 

while upon the trunk, it was either entirely absent or 
only a spot here and there to he found. Again, I have 
seen it thickly set upon the back ; and I am inclined to 
believe that it more frequently occupies this locality 
than is generally supposed. It is not so conveniently 
sought for in this region as upon the abdomen, chest, 
and extremities; and therefore results, perhaps, the 
rarity of its being spoken of as occupying this region. 
All this I have observed in mild cases of the disease. 

In the intermediate form of the disease, I have occa- 
sionally observed it largely spread over the different 
parts of the surface, but this was rare when compared 
with its frequency in milder cases. In this form it is 
mainly confined to the abdomen, with, perhaps, a patch 
now and then to be seen upon the breast and shoulders. 
It is also somewhat later in its appearance than in the 
mild form. In cases of still greater severity — those 
belonging to the malignant form — it is, as a general 
rule, still more tardy in its appearance, and does not 
occupy as much surface at a time as is usually seen in 
the preceding forms. It has been in the worst cases of 
the disease that I have observed the smallest amount of 
this eruption. In a very few instances I have seen it 
thickly spread upon the abdomen, chest, and shoulders, 
with a few spots on the back and thighs; but, in the 
majority -of severe cases, it occupied only the region of 
the abdomen. It does not always make its appearance 



ROSE-COLORED ERUPTION. 57 

upon all of the several parts of the surface named at 
the same time, but comes out in successive crops — 
sometimes abundant in one region, and at other times 
only one, two, three or four spots in the next locality. 
When the first patch begins to fade, a second will make 
its appearance, and so on, until the eruption ceases, or 
is lost in the larger and more livid discolorations, known 
as petechia, which, in very grave cases, show them- 
selves. The time occupied in this fading and recur- 
rence of the eruption may vary from five to twenty-five 
days. The greatest duration of this process I have no- 
ticed, almost invariably, to occur in those cases which 
passed through the milder forms to the malignant, and 
particularly in those cases which terminated in death. 
In the majority of these cases but few spots could be 
found at a time after the most careful search. 

Among children this eruption is generally earlier in 
its appearance than among adults, and does not usually 
occupy the average duration in the latter. 

"These spots," says Professor Wood, "must not be 
confounded with petechia, which also appear in this 
disease, but are by no means peculiar to it. The latter 
can scarcely be considered strictly as an eruption, con- 
sisting merely of blood extravasated in the skin. They 
are distinguishable usually by their more livid color, by 
never projecting above the surface, and by not disap- 
pearing upon pressure. They occur much less fre- 



58 ENTERIC FEVER. 

quently in enteric fever than the rose-colored eruption, 
and are more common in genuine typhus fever than in 
that disease. Sometimes the hemorrhagic effusion is 
more extensive, constituting patches or vibices." — Prac. 
Med., vol. i. p. 320. 

I may here allude to another eruption seen to accom- 
pany enteric fever, called Sudamina. It consists in 
transparent vesicles, varying in size from a pin's head 
to that of a barley-grain, and even larger, of circular 
or oval shape, and produced by the deposit of a limpid 
fluid beneath the cuticle, and by which it is elevated. 
These vesicles may usually be detected by the touch, 
but to be seen may require that they be viewed in an 
oblique direction. It is said to show itself most fre- 
quently upon the sides of the neck, in the axillas and 
about the front and upper part of the shoulders. When- 
ever I have observed it, it always occupied those locali- 
ties. By some observers it is considered a frequent 
accompaniment of the disease, and they attach to it 
importance as a diagnostic sign.* It is said also to oc- 
cupy, sometimes, a large extent of surface — almost the 
whole body being covered with it except the face.f I 
have already spoken of the comparative rarity with 
which I have noticed this eruption in enteric fever. I 



* Bartlett on Fevers, p. 61. 
f Wood's Practice, p. 320. 



HEMORRHAGE. 59 

repeat, I have witnessed it in but few cases, although I 
have carefully searched for it at the time that it is said 
most frequently to show itself — at a late stage of the 
disease ; but when seen, was in cases belonging to the 
intermediate form, preceded for a day or two by free 
perspiration. It is proper to remark that my expe- 
rience in this particular has not been the uniform ex- 
perience of other practitioners almost in my immediate 
locality. A highly respectable and intelligent acquaint- 
ance, Dr. A. Spitler, late of Buckkannon, Upshur 
County, Virginia, but now of Carthage, Illinois, in- 
formed me that from the frequency with which he had 
observed sudamina, he was led to attach importance to 
it, not only as a diagnostic sign, but to consider it a cri- 
tical eruption, and, deeming it such, he always searched 
for it after the fifteenth day with no little anxiety. 

9. Hemorrhage. — This is a frequent symptom in en- 
teric fever. It generally first makes its appearance 
by epistaxis, and this may occur very early in the dis- 
ease. In mild cases it is not usual for it to become 
profuse at any stage, not more perhaps than a few 
drops at a time, which may happen several times during 
the progress of the disease. In grave cases blood fre- 
quently flows copiously from the nostrils. "When nar- 
rating the symptoms connectedly of the intermediate 
form, mention was there made of these large losses 



60 ENTERIC FEVER. 

Tvliicli sometimes take place. In the most severe form 
of the disease there may be added hemorrhage from the 
gums. The next and most extensive losses take place 
from the bowels. Several times I have seen the usual- 
sized jiot filled with blood at a single sitting, and in one 
case, immediately succeeding the discharge, which was 
the first one of the kind, the patient sank from his 
chair to the floor, exclaiming as he was about to fall, 
"I am dying!" He was carried to bed almost lifeless. 
In this case hemorrhage succeeded hemorrhage, until 
the eighth day, from the first one, when he died. 

In some cases the blood thus discharged is red, and 
but little changed ; in others it is dark and disinte- 
grated. Of the thirty-four cases belonging to the 
gravest form of the disease, eighteen suffered more or 
less hemorrhage from the bowels. Of these eighteen, 
eight were fatal. But the nostrils, gums, and bowels 
are not the only parts from which blood may flow. In 
a few cases I have known the urine to be retained by 
firm coagula in the bladder. In one case, a male, I 
had to break up and dilute a coagulum by injections 
into the bladder of flaxseed tea, before the urine could 
pass out through the catheter, and yet, notwithstand- 
ing this operation had to be performed regularly for 
several days, the patient recovered. Another example 
of hemorrhage is petechia, which shows itself toward 
the close of fatal cases. 



FORMATION OF ESCHARS. 61 

10. Tendency to the Formation of Eschars. — At a 
late stage of the disease, when the blood has become 
vitiated and the constitutional powers diminished, 
sloughing of the skin on parts exposed to pressure, 
such as the sacrum, the trochanters, and the shoulders, 
is likely to occur. The skin covering these parts be- 
comes congested and inflamed, and speedily becomes 
excoriated without the least pain being complained of 
by the patient. If blisters have been drawn, they are 
frequently attacked with ulceration. " They become, 
especially about their edges, covered with a white or 
grayish exudation, like that which is frequently seen 
on blistered surfaces in cases of protracted scarlatina, 
and which is commonly called canker. The ulceration 
underneath this matter sometimes becomes deep and 
extensive, adding, in no small degree, to the irritation 
of the disease. In some cases true gangrene occurs, 
followed by eschars and extensive sloughing."* In all 
grave cases this tendency to excoriation of the skin on 
points pressed upon should not be overlooked, and 
should it occur in spite of the efforts to prevent it, 
means must at once be adopted to relieve the parts 
from further injurious compression. Great care is ne- 
cessary in preventing the contact of faeces or urine, be- 
cause of their additional influence to produce softening 

* Bartlett's Treatise on Fevers. 
6 



b'l ENTERIC FEVER. 

of the subcutaneous cellular tissue corresponding to the 
inflamed patch. When a slough has once formed, it 
may extend by a process of undermining of the integu- 
ments, and on its separation disclose extensive mischief. 
These bed-sores are troublesome things to manage, and 
always render the period of convalescence exceedingly 
tedious and uncertain. 



CHAPTER IV. 

ANATOMICAL LESIONS. 

If I were compelled to rely upon my own observa- 
tion for a description of the changes found in the 
several organs and structures after death from enteric 
fever, I should omit this chapter entirely. In country 
practice the physician may enjoy extensive opportuni- 
ties of learning symptoms, and by this knowledge be 
able to assign to each its due value as regards the diag- 
nosis and prognosis of the disorder, but concerning the 
changes found on dissection, which have given rise to 
the living morbid phenomena, his opportunities for ob- 
serving are confessedly limited. To obviate this sen- 
sible defect of my own experience, which otherwise 
would materially diminish the value and completeness 
of my treatise, I copy from Dr. Wood his account of 
the morbid anatomy of the disease. He says: "There 
is scarcely a single organ of the body in which signs of 
inflammation are not sometimes found after death from 
enteric fever, for it is one of the peculiarities of this 
affection, or possibly of the febrile movement, which, in 
this affection, is of unusual duration, to develop local 

(63) 



64 ENTERIC FEVER. 

disease of an inflammatory nature. But there are cer- 
tain anatomical changes which are especially character- 
istic of enteric fever, and which are so seldom wanting 
that they may be considered as almost essential. Such 
is the affection of the elliptical patches of aggregated 
mucous follicles in the ilium, denominated the glands of 
Peyer. This is quite as characteristic of the disease in 
question as the peculiar pustular eruption is of small- 
pox. It has in fact come to be regarded almost as a 
necessary post-portem test of the existence of the dis- 
ease. The affection had been observed by various 
pathologists, as by Stark, Petit, and Bretonneau, but it 
is to Louis that the credit is especially due of fixing its 
precise relation to this form of fever. The facts ascer- 
tained by the last-mentioned pathologist in relation to 
the enteric fever of Europe, have been proved by the 
dissections of Drs. Gerhard, Jackson, Bartlett, and 
many others, to be equally applicable to the disease as 
it prevails in the United States. 

"The opportunity has not yet been offered of ascer- 
taining the condition of the glands of Peyer in the 
earliest period of the disease. They have been ex- 
amined, however, at all stages after the sixth day. At 
first the patches are observed to be thickened, and their 
surface elevated one, two, or even three lines above that 
of the surrounding mucous membrane. The largest are 
from two to three inches long, and from half an inch to 



ANATOMICAL LESIONS. 65 

an inch broad ; the longest diameter being in the direc- 
tion of the intestine. Some are smaller and more cir- 
cular. Their edges are in general clearly defined, 
smooth, and regular, but sometimes irregular and 
ragged. Some of them are dark-red, some pale, and 
others of an intermediate hue. There are two varieties 
of them, distinguished by Louis by the names of hard 
and soft. The former are hard to the touch, and, when 
dissected, are found to contain, beneath the mucous mem- 
brane, and resting upon the muscular coat, a layer of 
white or yellowish, firm, brittle matter, the cut surface 
of which is smooth and shining. The latter are softer, 
less elevated, and destitute of the whitish layer above 
mentioned, their elevation, when at all observable, 
being caused by an inflammatory thickening of the 
mucous membrane covering the patches, and of the 
submucous cellular tissue. In these, the mucous surface 
appears at first granular or finely mammellonated, with 
innumerable small orifices, which give it a reticulated 
appearance ; a condition which is ascribed by Louis to 
enlargement of the several follicles. This character is 
lost in the progress of the affection, the surface be- 
coming uniform, smooth, and still softer. Sometimes 
the same elliptical patch exhibits both the forms just 
described, one in one part of it, the other in another; 
and often some of both varieties are found in the same 
case. The patches vary in number from one up to 

6* 



66 ENTERIC FEVER. 

thirty, averaging, perhaps, ten or twelve. They appear 
upon the surface of the intestine opposite to the mesen- 
tery. They do not all originate at once, but in general 
come successively, those near the ileo-ccecal valve first 
appearing, and afterwards those higher up, even into 
the jejunum. The consequence of this successive ap- 
pearance is a difference in the degree of their develop- 
ment, the oldest being the most advanced. 

"The hard patches may undergo resolution or ul- 
ceration; the soft always ulcerate. In the former, the 
matter deposited beneath the mucous membrane first 
softens and separates from its connections, so as to be 
thrown off when the mucous coat above it is removed. 
The surface is found in various stages of ulceration; 
but, when the process is completed, the whole patch 
constitutes one ulcer, which sometimes remains of the 
original size, sometimes spreads, and is occasionally 
stained yellow by the bile. In some instances the floor 
of the ulcer is the muscular coat, in others, in conse- 
quence of the destruction of that tissue, it is the peri- 
toneal coat, and this occasionally is found penetrated, 
so as to form a communication with the cavity of the 
peritoneum. Out of fifty-five cases which he examined, 
Louis found eight of perforation. Sometimes there was 
only one orifice,' sometimes two or three. The opening 
was in the centre of the ulcerated patches, and always 
in the vicinity of the ccecum. The perforation is pro- 



ANATOMICAL LESIONS. 67 

duced either by the progress of ulceration, by mortifi- 
cation of the uncovered peritoneal membrane, or by its 
rupture from force applied within the bowel. 

"The ulcers are not necessarily fatal. On the con- 
trary, dissection has afforded abundant proof that they 
have a tendency to heal. In the process, the elevated 
border is depressed, the cavity is filled by granulations, 
and the surface is ultimately covered with a new mucous 
membrane, which, though at first smooth, more glossy, 
and more tender than the healthy membrane, in the end 
cannot be distinguished from it. 

"The solitary mucous follicles of the ilium, fre- 
quently denominated, though perhaps erroneously, the 
glands of JBrunner, the glands properly so named being 
situated in the duodenum, are usually affected in the 
same manner as the glands of JPeyer, being enlarged so 
as to be distinctly visible, and either hard or soft, ul- 
cerated, etc. These diseased follicles are scattered, in 
larger or smaller numbers, over the whole circumference 
of the lower portion of the ilium, and are sometimes 
found also in the colon. Occasionally the elliptical 
patches are alone affected; and it is asserted that, in 
some rare instances, the solitary glands have been 
diseased without any affection of the patches.; but, in 
general, they are both more or less diseased. The ag- 
gregated glands are more frequently ulcerated than the 
solitary. 



bS ENTERIC FEVER. 

" The mucous membrane of the ilium, between the 
affected glands, generally exhibits signs of disease, 
being sometimes thickened by sanguineous infiltration, 
sometimes softened, and sometimes of a white or gray- 
ish color, though more generally reddened. 

" The mesenteric glands are as constantly diseased as 
the mucous follicles. Those corresponding with the 
morbid patches are most affected, but not exclusively so. 
The glands are reddened, enlarged, and softened, and 
sometimes exhibit traces of pus, though very rarely in 
such quantities as to form an abscess. As they become 
diseased with the patches, so do they also return along 
with these to the healthy state. The lymphatic glands 
elsewhere are also, sometimes, enlarged and reddened, 
but less frequently, and in less degree, than those cor- 
responding with the diseased glands of Peyer. 

" The lesions above described are those characteristic 
of the disease. There are numerous others, which, 
being incidental, require only a brief notice. 

" Other parts of the alimentary canal, besides those 
mentioned, are often diseased. The pharynx was found 
by Louis in one-sixth of the cases, either ulcerated or 
coated with false membrane, or infiltrated with pus. 
The oesophagus was ulcerated about as frequently, the 
ulcers being generally small, and sometimes numerous. 
The gastric mucous membrane was more frequently 
quite natural than in subjects who had died of any 



ANATOMICAL LESIONS. 69 

other acute disease; but it was, nevertheless, often 
diseased, being softened, reddened, thinned, mammel- 
lonated, ulcerated, etc. The softening, which is the 
most frequent lesion, though sometimes inflammatory, 
is thought not to be so in many instances. The duode- 
num is not often much affected. Its lesions are similar 
to those of the stomach. The colon is almost always 
distended with air, sometimes enormously so. Occa- 
sionally, isolated mucous follicles are found diseased 
like those of the small intestines; and a few small, 
round patches, similar to those of the ilium, have been 
observed in a very few cases. The mucous membrane 
sometimes shows signs of inflammation, such as redness, 
softness, and ulceration. 

" The spleen is in almost all cases more or less al- 
tered, being generally enlarged and softened, and some- 
times very much so. In some instances, it is four or 
five times the usual size, and softened to the condition 
of a bloody pulp, through which the finger will pass 
readily in any direction. 

"The liver is also frequently softened, though in a 
less degree, and is otherwise variously altered, but 
without any constant or characteristic lesion. The 
same may be said, in a still less degree, of the kidneys. 
The gall-bladder and the urinary passages have been 
found inflamed, in a very few instances. The heart is 
sometimes softened, and the inner coat of the aorta 



70 ENTERIC FEVER. 

tinged red with blood, probably from imbibition. In 
relation to the respiratory organs, the epiglottis and 
larynx are sometimes, though rarely ulcerated, or coated 
with inflammatory exudation ; the bronchial membrane 
is often reddened; and signs of congestion, inflamma- 
tion or apoplectic sanguineous effusion, are observed in 
the parenchyma of the lungs. The brain exhibits fewer 
evidences of disease than might have been suspected 
from the symptoms. In a large proportion of cases it 
is quite healthy. Sometimes the membranes appear 
congested or inflamed; serous effusion has been ob- 
served; and the substance of the brain has exhibited 
red points when cut. But no satisfactory connection 
has been traced between these lesions and the symptoms 
of cerebral disorder evinced during life. 

" The blood drawn during life often does not appa- 
rently differ from its condition in health. It coagulates 
firmly, and, unless the disease is attended with some 
accessory inflammation, exhibits no buffy coat. But if 
pleurisy, pneumonia, or rheumatism be superadded, the 
inflammatory crust appears, though usually soft, and 
sometimes gelatinous. Sometimes, in low typhus cases, 
the blood is either but partially coagulable, or wholly 
uncoagulable. It has been found in both states after 
death. "When uncoagulated it is sometimes mixed with 
air. It generally contains a smaller proportion of fibrin 
than healthy blood. 



ANATOMICAL LESIONS. 71 

"Many of the above phenomena indicate the exist- 
ence of inflammation in connection with the fever; but 
the softness which has been noticed in so many organs 
is thought, by the best pathologists, not to be inflamma- 
tory, but rather the result of a direct loss of vital co- 
hesion in the organs, either from debility, or the state 
of the blood." — Practice of Medicine, vol. i. p. 324. 



CHAPTER V. 

HISTORY AND CAUSES. 

1. Enteric fever has become a common disease in 
Virginia, and in some localities has almost completely 
supplanted the bilious-remittent form, which was of 
such frequent occurrence in former years. This re- 
mark applies with especial truth to some sections of 
Eastern and Southeastern Virginia. In this low 
country of the State, prior to the last twenty-five or 
thirty years, periodic fevers were the only forms of 
fever to be met with, but since then they have been 
gradually giving place to the enteric or typhoid 
form, and now, in some particular localities, the latter 
is as common as was the former. Dr. L. Faulkner, of 
Halifax County, in a letter to me, dated October 1st, 
1858, says: "With us typhoid fever has become a fre- 
quent disease. We have also bilious-remitting fever, 
and there is frequently a modifying influence exerted 
by the one upon the other. Typhoid fever sometimes 
sets in, with prominent biliary derangement, and in 
these cases it is not uncommon for well-marked remis- 
sions to occur during the first five or six days. In such 
(72) 



HISTORY. 73 

cases quinine fails to arrest the disease, if indeed it 
does not aggravate it. In 1854 the majority of cases 
of typhoid fever occurring in this section was obscured, 
for the first several days, by the conditions just men- 
tioned. On the other hand, I have seen remittent 
fever with all the prominent symptoms of typhoid in 
the beginning, there being no well-marked remissions 
until the case was subjected to proper treatment, when 
its true colors would be run up, and the desired quinine 
state hailed with joy." * 

Dr. Robert A. Gholson, of Petersburg, in a letter 
dated September 14th, 1858, says : " Typhoid fever 
began to show itself in this region in an unequivocal 
form, soon after the epidemic of erysipelatous fever 
which visited us in the year 1845. During the sum- 
mer of 1850 I met with a most malignant form of 
continued fever among the blacks on several plan- 
tations in the County of Greensville.* Since the 
occurrence of this endemic, I have occasionally met, 
both in country and city, with sporadic cases of the 
disease." Concerning bilious-remittent fever in his 
locality he remarks: "This form of fever is not of un- 
frequent occurrence among us, but in many instances it 
is so changed as not to be easily distinguished, in the 
beginning, from continued or typhoid fever. It is con- 

* See Dr. Gholson's Keport in the July number of the Virginia 
Medical Journal, 1857. 



74 ENTERIC FEVER. 

fessedly a rare thing to meet with the old-fashioned (as 
it is called) remittent fever of this climate. So great 
is the change which its character has undergone that it 
would hardly be recognized now by those who met with 
it, say some twenty-five years ago." 

Dr. AVilliam W. Parker, of Richmond, to whom 
I am greatly indebted for a valued letter dated 
November 24th, 1858, says: "A highly intelligent 
physician of this city, who has been in practice some 
forty years, informs me that he is now well satis- 
fied of having met with cases of typhoid fever in 
the early years of his practice, though then called 
by a different name. The disease was then very rare, 
certainly so in comparison to its frequency at the 
present time. That the disease is on the increase in 
this part of the State, and that it has been especially 
so observed during the past eight or ten years, is the 
uniform opinion. Yet, along with its increase in fre- 
quency, it has I think materially lessened in severity. 
For the last two or three years it has been generally 
very mild in its character." Concerning bilious-remit- 
tent fever he adds: "It seems to be the prevailing 
opinion in the lower country that typhoid fever is gra- 
dually taking the place of the ordinary bilious fever of 
that district, and an intelligent acquaintance informs 
me that the two affections are sometimes so intimately 
blended with each other that it is with the greatest 
difficulty in the beginning to say which of the influ- 



HISTORY. 75 

ences will preponderate. I have often myself mistaken 
typhoid fever in the beginning for bilious-remittent 
fever. Latterly, however, I have aided the diagnosis 
by a gentle purgative." 

Through the kindness of Dr. Charles R. Cullen, of 
Hanover County, I am in possession of an interesting 
letter from Dr. Carthon Archer, of Henrico County, 
dated November 12th, 1858, who says: "Bilious-remit- 
tent and intermittent were the prevailing types of fever 
until within the last twelve or fifteen years, when they 
became less frequent, and the continued or typhoid 
form took their place. Intermittent fever still prevails 
to a considerable extent upon James River, but bilious- 
remittent fever is seldom met with. With regard to 
the present frequency of typhoid fever in this region of 
the State, I do not think that more than one or one- 
half per cent, of the population is annually attacked by 
it, though I have no positive statistics in regard to it. 
The disease was more fatal last year, during the heat 
of the summer and early part of autumn, than any 
other year or season in my experience. I have seen 
several cases which commenced with well-marked symp- 
toms of intermittent fever, and in which subsequently 
all the symptoms of typhoid fever were unequivocally 
developed. Nor could it be thought in these cases that 
the typhoid symptoms were the result of improper 
treatment, as especial care was taken to avoid any 



76 ENTERIC FEVER. 

treatment tending to produce or exasperate any exist- 
ing intestinal irritation." 

Passing along round the tide-water boundary, and 
over a district of country in which the disease is more 
or less frequent, we come to Alexandria, from which 
point I have an interesting letter from Dr. Charles W. 
Chancellor, dated February 11th, 1857. He says: 
"Enteric or typhoid fever is not a common disease in 
Alexandria and its vicinage, but was known to our 
oldest physicians in the early years of their practice, 
and undoubtedly existed here before they made their 
professional debut. As a rule we can only claim the 
existence of the disease in sporadic cases; certain it is 
we have never had it as an epidemic. Nor has it ex- 
isted here, to my knowledge, in an intractable or ma- 
lignant form, being generally of mild character, and 
running its course in from three to six weeks. Bilious- 
remittent fever is of frequent occurrence in the fall of 
the year, and often assumes a very low and asthenic 
character ; but even in the lowest grades of this fever, 
according to my own observation, there is always a 
well-marked period of remission, whereas in typhoid 
fever the febrile symptoms continue usually with little 
or no remission. I have never met with a case in 
which I believed the lesions of the two diseases existed 
simultaneously." 

Advancing from this point toward the Blue Ridge, 



HISTORY. 77 

we come to Loudon, from which county I have a letter 
from Dr. W. Cross, of Leesburg, dated February 13th, 
1857. Dr. Cross says: "As well as my recollection 
serves me, and as far as I have been able to get infor- 
mation upon the subject, typhoid fever first appeared 
in this and the adjacent counties somewhere about the 
year 1845. The cases have not been numerous, hut 
greatly on the increase in the course of the last year or 
two. During the last year, I suppose some twenty 
cases have occurred on an average, in a range of eight 
square miles. It was also more fatal during the last 
year than any other year of my experience, the patient 
sinking calmly into death, sometimes in a few days, at 
other times under excessive jactitation, with great men- 
tal derangement. The disease has never prevailed here 
as an epidemic. I have occasionally met with cases of 
bilious-remittent fever in my practice." 

Passing along the Eastern base of the Blue Ridge, 
through the Counties of Fauquier, Rappahannock, and 
Madison, in which the disease is more or less frequently 
observed, we arrive at Green, from which county I have 
a letter from Dr. Y. C. Blakey, of S^anardsville, elated 
August 20th, 1857. The doctor writes: "Typhoid 
fever first made its appearance in this and the sur- 
rounding counties about the year 1845. In relation to 
its frequency, sometimes it is met with more or less 

often for two or three years in succession, then again 

7* 



78 ENTERIC FEVER. 

we are exempt for the same length of time. Its cha- 
racter as regards gravity, has been tolerably uniform, 
the disease being generally amenable to the proper 
treatment. Bilious-remittent fever has been a rare dis- 
ease with us for fifteen years past. I have never wit- 
nessed a 'blending' of the two affections." 

Proceeding in the same direction, and passing the 
Counties of Albemarle, Nelson, and Amherst, in all 
which the disease is more or less common, we come to 
Bedford County, from which I have a most satisfactory 
letter from Dr. P. C. Sutphin, dated October 20th, 
1858, which says: "Typhoid fever is quite a common 
disease with us, occurring more or less often every 
year. It is usually regarded as having first made its 
appearance in our midst about the year 1843, when it 
prevailed in an epidemic form, sweeping off a great 
number of our citizens. Since the appearance of this 
epidemic the character of the disease as regards gravity 
has been tolerably uniform, being generally mild. 
Bilious-remittent fever is not often met with in Bed- 
ford. In a few instances I have observed a 'blending' 
of the two diseases. I have seen bilious fever become 
so feeble in its remissions as to lead to the belief that 
it had lost its remittent type and assumed the con- 
tinued form." Corresponding with the experience of 
Dr. Faulkner, of Halifax, Dr. Sutphin adds: "In the 
County of Halifax there is such an apparent commin- 



HISTORY. 79 

gling of types that it is nothing uncommon for physi- 
cians of that section to characterize remittent as 
Hyphoid-remittent fever.'" 

In the district of country embracing the Counties of 
Franklin, Henry, Pulaski, Wythe, Washington, and 
Lee, the disease is equally common, and sometimes has 
been exceedingly fatal in its character. Of the date 
of its advent in these counties I have no reliable infor- 
mation. 

Turning our course and skipping the Counties of 
Tazewell, Mercer, Giles, Craig, Alleghany, Botetourt, 
Bath, and Rockbridge, for want of reliable data, we 
come down the Valley to Augusta, from which county 
I have positive information. Dr. C. R. Harris, of 
Mount Sidney, in a letter dated February 2d, 1857, 
says: "I have practiced medicine for fifteen years, and 
in this time have met with three epidemics of typhoid 
fever ; but every year, and at all seasons, I have occa- 
sionally met with sporadic cases. The mortality in my 
practice during the epidemics of 1843, 1844, and 1852, 
amounted to some three or four deaths — in near 200 
cases. I have met, now and then, with cases of bilious- 
remittent fever, some of which I have seen merge into 
the typhoid state, but have never observed a ' blending ' 
of the two affections. In the management of my ty- 
phoid fever patients I have pursued ' a course of mas- 
terly inactivity ' — watched the patient closely ; adminis- 



80 ENTERIC FEVER. 

tering mild laxatives (after a mercurial purge early in 
the attack;) then, in the language of Broussais, listen- 
ing to the cry of the suffering organ, combating local 
inflammation by revellents; sustaining the system by 
nutritious broths ; dark room, and quiet nurse ; cold or 
tepid sponging; opiates to insure rest: these constitute 
the sum total of my practice. Late in the disease it is 
important to watch the tendency to death; whether by 
coma, anaemia, asthenia, or apnoea, and treat accord- 

i»gly." 

In the Counties of Highland, Pendleton, and Rock- 
ingham, the disease is more or less often met with every 
year. During some years, in the Counties of Highland 
and Pendleton, the disease has not only been very fre- 
quent, but exceedingly malignant in its character. In 
the County of Rockingham, Dr. John Q. Winfield has 
seen much of the disease. Dr. Harvey Moffett, of 
Harrisonburg, speaks of its frequency within the limits 
of his practice. In the Counties of Page, Warren, and 
Shenandoah, the disease has shown itself more or less 
often for the past fifteen years. A valued friend, Dr. 
Jacob Neff, of New Market, Shenandoah County, in a 
letter dated February 6th, 1857, says: "I cannot say 
exactly the time when typhoid fever first made its ap- 
pearance in this part of the Valley. Certain it is, I 
have met with the disease for the last ten or twelve 
years, and quite often in the last five or six years. My 



HISTORY. 81 

experience leads me to look upon typhoid fever as a 
grave disease, and one in which we may both hope and 
fear constantly. I have seen very low conditions re- 
covered from, and I have also seen cases which were 
entirely free from the ordinary symptoms of malig- 
nancy, in which death suddenly and unexpectedly oc- 
curred. The disease, I think, cannot be broken up 
suddenly by any method of treatment, yet by watching 
the symptoms closely, and employing such means as ex- 
perience has proved best for their relief, we may conduct 
the large majority of our patients to convalescence." 
In the same county, during the years 1848 and 1849, 
Dr. Samuel Coffman witnessed a severe endemic in the 
neighborhood of Mount Jackson. Dr. Meim, of that 
vicinity, witnessed the same scourge. The Drs. Henkle, 
of New Market, have also seen much of the disease. 

In the Counties of Frederick, Clark, Jefferson, 
Berkeley, and Morgan, the disease is of greater or less 
frequency every year. In Winchester, and the adja- 
cent country, Dr. Robert Baldwin has frequently met 
with enteric fever during the last twelve years. In 
Morgan County it has been extremely severe. Dr. J. 
W. Brown, of that county, writes me from Bath, dated 
9th February, 1857, that "Morgan County has suffered 
more from typhoid fever, in all its phases, than from 
any other disease." Continues the doctor: "The first 
I saw of the disease was in 1843, when some five cases 



82 ENTERIC FEVER. 

occurred, and one death. From 1843 to 1855, the 
disease was pretty uniform in its character, the average 
number of deaths being about one in twenty. In 1856, 
I met with sixty cases, thirteen of which were fatal. 
We have, also, more or less bilious-remittent and inter- 
mittent fever ; and sometimes I have observed a ' blend- 
ing' of the remittent and continued form, though 
generally the distinctive character of each affection is 
well preserved. Concerning bilious-remittent, intermit- 
tent, and typhoid fever in Morgan, I may mention a 
curious circumstance which came under my observation. 
In 1856, the south end of our county was severely 
visited with typhoid fever; in the opposite direction 
many cases of bilious-remittent and intermittent fever 
occurred. The district of country which I speak of as 
south, is divided by a ridge running parallel with the 
great Ca-Capon Mountain, and forms a valley, say two 
miles wide by eight miles long. In this valley not a 
case of typhoid fever occurred — all the cases there 
being bilious-remittent and intermittent fever; but on 
the other side of the ridge there occurred some sixty 
cases of typhoid fever, and of a most malignant cha- 
racter. Of these, twelve were fatal. For this differ- 
ence I am wholly unable to account. The country is 
similar in soil, in elevation, and in the habits of the 
people." 

Coming west of the Alleghany Mountains, we find 



HISTORY. 83 

enteric fever not only of great frequency, but assuming 
its genuine character. Indeed, so frequently has North- 
western Virginia been scourged by the disease, during 
the past fifteen years, and so exceedingly fatal in some 
of the counties, that it will long be remembered by 
many, whom it caused to mourn the loss of friends and 
relatives, cut off by its ravages, alike in the bloom of 
youth and the ripeness of mature age. 

Dr. J. A. McLane, of Morgantown, Monongalia 
County, in a letter dated February 12th, 1857, says: 
"In this comity, and in the western portion of Preston, 
we have had enteric or typhoid fever, in epidemic form, 
more or less frequently, since the autumn of 1845. In 
the County of Preston it first showed itself as an epi- 
demic, in the latter part of the summer of 1844, and 
was known by the general sobriquet of ' Evansville, or 
Black-tongue Fever.' There was nothing peculiar in 
the character of this epidemic from that which the 
disease at present assumes, unless it was an association 
of meningitis, which manifested itself in almost all 
cases of a protracted character. The worst epidemic 
we have ever had occurred in the year 1853, and com- 
menced about the first of September. The peculiar 
disposition exhibited in nearly every case, was an early 
and well-marked inclination to hemorrhage. The most 
extensive hemorrhages by the bowels were not unfre- 
quent as early as the tenth or twelfth day. Since the 



84 ENTERIC FEVER. 

date of its first recognition in Monongalia, it has oc- 
curred in the various sections of the county more or 
less extensively every year to the present." 

From "Wheeling I have a letter from Dr. E. A. Hil- 
dreth, dated February 18th, 1857. - The doctor says : 
"From the best authority at hand, typhoid fever vras 
first distinctly recognized here in the winter of 1833 
and 1831, and prevailed to a greater or less extent for 
the two succeeding years ; after which it seemed to have 
left us, and our old-fashioned bilious-remittent fever re- 
sumed the sway. From 1837 we met with no fever 
having the continued or typhoid type, until after the 
epidemic cholera of 1849, since which time we have had 
nothing but typhoid fever. In 1850 and 1851, the ma- 
jority of cases were of grave cast: there was great 
tympanitis, tenderness of the abdomen, and profuse 
diarrhoea. Since 1851 the poison seems to expend 
itself most on the brain — there is almost constantly 
delirium and coma, and in fatal cases, spasmodic rigidity 
>f the extremities." 

Dr. A. Payne, of Pruntytown, Taylor County, in a 
letter dated February 3d, 1857, says: "I am unable to 
give the date of the advent of typhoid fever in Taylor. 
I came to the county in 1847, and found a few cases, 
some two or three of which proved fatal. The disease, 
I learned, had not been common, and I saw nor heard 
nothing more of it, with the exception of here and there 



HISTORY. 85 

an isolated case, until the summer of 1850, when it ap- 
peared as an epidemic, and was fatal to a fearful ex- 
tent. In 1851 it passed off, and, with the exceptions 
before stated, did not appear until the latter part of 
January, 1853, when quite a number of cases occurred. 
From 1854 till the close of 1855, but few cases were 
met with ; but in 1856 it became again common, and so 
it continues to the present." 

Dr. A. Spitler, of Buckhannon, Upshur County, in 
a letter dated April 2d, 1857, says: "The first time 
typhoid fever was certainly known to visit our county 
was the summer of 1847. During that summer ten 
persons were attacked, one of whom died. Since 1847 
it has prevailed more or less extensively every year to 
the present, but was most frequent in 1848 and 1852. 
The mortality was greatest in 1851 and 1852." 

From Lewis County I have an interesting letter from 
Dr. W. J. Bland, of Weston, dated February 5th, 
1857. Dr. Bland says: " Typhoid fever was first re- 
cognized in this region of country in the year 1845. 
In the winter and spring of 1846, it prevailed on the 
Little Kanawha, in Braxton County. I attended 119 
cases, thirteen of which were fatal. It has made its 
appearance almost every winter and spring from that 
time to the present. It was more fatal in the winter 
and spring of 1848 than I have ever known; but as 
warm weather approached it grew milder. I do not 



bb ENTERIC FEVER. 

recollect the rate of deaths in any one year except as 
above stated." 

In the country bordering on the Ohio River, from 
Marshall to Wayne County, the disease is of equal fre- 
quency, and during the years between 1847 and 1853 
some of the counties included between these points 
were severely visited. 

2. Season. — Enteric fever certainly prevails oftenest 
during the autumnal and winter months, though it oc- 
curs at all months of the year. The 130 cases occurred 
as follows: January, 18; February. 7; March. 8: April, 
5; May, 5; June, 10; July. 3; August, 9; September, 
11; October, 18; November, 24; December, 12. 

Dr. Faulkner says: "We have more fever during the 
summer and fall months, but there are more cases 
occurring, of genuine typhoid character, during the 
autumnal and winter months, though I meet with the 
disease at all months of the year. This year I have 
met with more cases in the spring." Dr. G-holson 
thinks he meets with more cases of the disease during 
the summer and fall. Dr. Parker writes: "I have cer- 
tainly had more cases of typhoid fever this summer and 
fall than in any other year of my practice." Dr. 
Blakey says he has met with a greater number of 
cases in the fall and winter. Dr. Cross writes: "The 
disease oftenest shows itself in my practice late in 



CAUSES — CONTAGION. 87 

autumn and winter." Dr. Hildreth says: "The greatest 
number occurred the latter part of summer and during 
the fall months." Dr. Sutphin says: "It occurs with 
us most frequently in the latter part of summer and 
earlier fall months." Dr. Harris has met with more 
cases in the fall of the year. Dr. Neff thinks he has 
seen more of the disease in fall and winter. Dr. 
McLane writes: "The disease is both more frequent 
and grave during the fall and winter months." Dr. 
Spitler remarks: "The disease, in our county, has been 
more prevalent during summer and fall." In Dr. 
Bland's experience, it occurs oftenest in the winter and 
spring months. Dr. Payne thinks it has most fre- 
quently prevailed in winter. 

3. Contagion. — Concerning the contagiousness of en- 
teric fever there is much difference of opinion. Dr. 
Hildreth says: "This is truly a vexed question. If I 
ask half a dozen physicians, three declare it contagious, 
the other three as positively deny its being so, each 
party adducing their experience in support of their 
views." Dr. McLane says: "I have been much per- 
plexed on this subject, but have inclined to non-conta- 
gion." Dr. Spitler says: "If the disease is contagious, 
it is surely feebly so." Drs. Blakey and Harris say 
they have no evidence "whatever of its contagious- 
ness." Dr. Brown positively denies it being so. Drs. 



88 ENTERIC FEVER. 

Bland, Neff, and Payne, say that "it may be infectious 
to a certain extent." Dr. Chancellor says he has no 
authority which would warrant him in the belief that it 
is at all contagious. 

It is undoubtedly true that numerous instances occur 
in which patients sick of the disease are unable to 
refer their sickness to any appreciable cause, and 
more, that the disease frequently springs up in a neigh- 
borhood, and those constantly with the sick will escape, 
while those who have had no communication whatever 
will be attacked. But while all this is true and verified 
by my own experience, it is equally true that by com- 
paring the number of persons who escape after contact 
and proximity with the sick with that of those who be- 
come ill of the same affection, after such exposure, 
the latter number greatly preponderates. Dr. Sutphin 
says: "In regard to the contagiousness of typhoid 
fever I could say a good deal if I had leisure. The 
following must suffice. In the year 1843, a Mr. Wright 
of this county, (Bedford,) went to Roanoke on a visit. 
While there he contracted the disease, which then pre- 
vailed in that county, and among the friends whom he 
visited. After partially recovering, he returned home 
to his father's, in whose family there had been no fever. 
In a short time after getting home he relapsed, and the 
disease attacked several members of the family. Of 
those who visited this family a majority contracted the 



CAUSES — CONTAGION. 89 

disease, and thus typhoid fever, which, prior to the re- 
turn of Mr. Wright, had not existed in the neighbor- 
hood, became then quite common. Another instance of 
similar character: the disease was introduced into a 
certain neighborhood, previously free, by the removal 
into it of a negro girl who had contracted it from a 
family to whom she was hired. The girl was brought 
home to her mistress, in order that she should receive 
due attention, and it was but a short while thereafter 
until some five or six cases occurred among the other 
members of the family. From these it extended to se- 
veral neighboring families, all of whom had visited the 
house to which the sick girl was brought. Every case 
that occurred in that neighborhood came directly under 
my care, and to my certain knowledge no one took the 
disease who had not been in immediate communication 
with the sick, or in other words, that had kept aloof 
from the disease. Some, it is true, escaped who were 
directly exposed, but these fell far short of the number 
who, being exposed, took the disease." 

Dr. Faulkner relates the following: "In 1845 a young 
man, on account of threatened phthisis, left Lynchburg, 
where typhoid fever was then prevalent, and came to 
his mother's in this county, (Halifax,) where, at the 
time, there was not a case of typhoid fever. Soon after 
his arrival, he was taken down with as clearly-marked 
typhoid fever as I had ever met with. I saw him the 

8* 



00 ENTERIC FEVER. 

15th of July, and he died the 2d of August, with all the 
symptoms of intestinal perforation. His brother-in-law, 
who watched him most, was attacked on the loth of 
August, and a negro woman, who had emptied the 
chambers for both, was attacked the 27th of August. 
Then his mother, aged fifty-six, sister, and little niece ; 
only two of the family escaping, son of the negro 
woman, aged three years, and the wife of the brother- 
in-law." 

Dr. William W. Parker narrates the following : " Some 
time during the past summer two young ladies, from 
different parts of the State, paid a visit to a female ac- 
quaintance living in Charles City County. Upon their 
arrival at this friend's dwelling they found her sick of 
typhoid fever, on account of which they fled imme- 
diately to their homes. One of them resided in Peters- 
burg. This one had not long returned until she was 
attacked. The other lived in the country, and was also 
seized with the disease soon after getting home." 

Dr. Archer says: "I have heard of several well- 
authenticated instances in which a case has been intro- 
duced into a family previously healthy, and the disease 
immediately attacking other members of the family. 
Two or three instances of the same occurrence have 
fallen under my own observation. A lady had a ser- 
vant brought from Richmond to her farm in the 
country, sick of typhoid fever. No case of the disease 



CAUSES — CONTAGION. 91 

had, up to that time, occurred in her family for several 
years; but two weeks afterwards three other cases oc- 
curred. It is proper to remark that the servants who 
took the disease were not more exposed to it, if as 
much, as several others who escaped. Last summer a 
lady from Williamsburg, at which place typhoid fever 
was prevailing, visited her friends in this neighborhood, 
and soon after her arrival was taken sick of the disease ; 
and shortly afterwards several friends with whom she 
had been, were also taken down, but from these the dis- 
ease did not spread farther." 

Dr. Cullen thinks it contagious under some circum- 
stances. 

My own opinion is not wavering upon the subject, 
and I do not hesitate to declare my firm belief of its 
contagiousness. I have reserved the history of the dis- 
ease in Barbour County until now, because of the evi- 
dence of contagion which it will exhibit. 

Enteric fever was not recognized in Barbour prior 
to the year 1837. In October of that year, a gentle- 
man by the name of Selvey, who had been on a visit to 
Athens County, Ohio, was brought home sick of the 
disease, called at that time in Ohio, "slow fever" In 
three or four weeks after his arrival, his mother, father, 
and three brothers, were taken down with the disease ; 
the mother died. The last of November following, six 
of another family near by, took the disease, and one 



92 ENTERIC FEVER. 

died. In December it appeared in a third family; five 
of these had the disease, and three died. From these 
it sprang up in another family; five had the disease, 
and one died. The last of January, 1838, nine of 
another family had the disease ; four died. During the 
following spring and summer two other families took it ; 
nine of these died. In the winter of 1838 and 1839, 
several other families took the disease, amounting in all 
to twenty cases ; of these six died. From that time up 
to the winter of 1840 and 1841, there were occasional 
cases springing up throughout the country. But during 
the fall and winter of 1841, the disease appeared in 
another neighborhood, ten miles distant; several fami- 
lies were attacked; among which there occurred ten 
cases, and four died. In the fall of 1842, a merchant 
returned from the North, sick with the disease, (his 
neighborhood alike previously free;) several of his 
family took it, but none died. The following winter it 
appeared in another neighborhood; six had the disease, 
and three died. From this date up to the winter of 
1843, there were but few cases occurring; but during 
the next spring it made its appearance in still another 
neighborhood ; some ten cases occurred, and four died. 
During the year 1845 it was generally prevalent in the 
county; about thirty cases occurred, and but one or 
two deaths. From the close of the year 1845 up to the 
year 1851, the disease became less common ; but during 



CAUSES — CONTAGION. 93 

the spring and summer of the last-named year the ex- 
tent of its visitation exceeded that of any former year ; 
and the citizens of our village, particularly, suffered 
severely from the disease. 

Philippi is situated about ten miles west of the Laurel 
Mountain, on the Tygart's Valley River, forty miles 
from its junction with the Monongahela, which, for two 
miles above and five miles below, has a sluggish current. 
Across the river, immediately opposite Philippi, is a 
small village, Georgetown. The bank on that side is 
very low for a few hundred yards, spreading out into a 
level in extent of about ten acres, and bordered on both 
sides by high hills. The greater portion of this ground 
is inundated at every considerable rise of the river. In 
the spring of 1851 the construction of a bridge, con- 
necting Philippi with Georgetown, was commenced; 
adding about thirty to the population of this last-named 
village. Among the workmen, whose business required 
them to stand in the water, enteric fever began ; from 
these it occurred among the workmen in stone upon the 
banks, and from these to the citizens generally. Our 
side of the river, Philippi, was next attacked, extending 
from family to family. Several of the workmen at the 
bridge, on being taken sick, went to their families in 
various parts of the county, forming starting-points of 
the disease in their several neighborhoods. Other hands 
were employed to fill the places of those taken sick, but 



94 ENTERIC FEVER. 

were soon likewise taken down. Fresh workmen were 
again and again secured; but the disease as successively 
continued to attack them, until at last, during the year 
1852, the work was, in consequence of it, almost com- 
pletely suspended. 

In September of this year, 1851, there was a mena- 
gerie exhibited at Philippi, which was largely attended 
by the people of the county; the following night nine 
persons, in attendance during the day, began to. feel un- 
well, and had the disease. 

From 1851 to 1858, our county has never been en- 
tirely free from the disease for more than a few months 
at a time. During this period it has been wandering 
about the different neighborhoods, at one time mild, at 
another severe, attacking one neighborhood this year, 
another the next; and then, perhaps, returning to the 
locality it visited the year before. The fall and winter 
of 1855, the disease was uniformly severe. The sum- 
mer was wet throughout; vegetation grew rapidly and 
was abundant. Heavy frosts appeared early, and the 
offensive exhalation from the decomposition of vegetable 
matter was remarkable. Hemorrhage from the bowels 
was of frequent occurrence at this season. 

I could bring forward other testimony of the conta- 
giousness of enteric fever in abundance, but this I deem 
unnecessary, and shall content myself with the following 
single instance: — 

Riley M., aged twenty-four, a farmer, visited an ac- 



CAUSES — CONTAGION. 95 

quaintance sick of the disease, October, 1855, distant 
some ten miles. There was no fever in Mr. M.'s 
neighborhood at the time of his visit to this friend, nor 
had there been for several years; but in two weeks 
after his return, he took the disease at his father's 
dwelling, and in twenty- eight days died. In ten or 
twelve days after his death, his sister, two brothers, 
mother and father, took it; the mother died. Among 
those who visited Mr. M., during his illness, was a 
cousin, a girl of nineteen, and a male friend, both of 
whom immediately contracted the disease; the cousin 
died. From these, other cases occurred in the neighbor- 
hood, no one taking the disease who had not visited the 
sick. Others were exposed also, but were not attacked. 
Dr. Elam D. Talbott, of Philippi, who has watched 
the progress of the disease in Barbour from the date of 
its advent, in 1837, to the present, is a firm believer in its 
contagiousness. This gentleman has met with the dis- 
ease more often than any other of his county brethren ; 
and though his usefulness is for the present denied, on 
account of the heavy hand of affliction which rests upon 
him, his long successful practice will be remembered by 
the community and acknowledged by his professional 
acquaintances. 

4. Exemption from Second Attacks. — Like other 
contagious affections, the occurrence of enteric fever is 



Vb ENTERIC FEVER. 

almost perfect security against a subsequent attack. 
The gentlemen whose names I have mentioned, without 
an exception, say they never knew an individual to have 
the disease a second time. Dr. Bland, of Weston, says : 
" To this fact my attention has been particularly directed, 
and I have frequently made inquiry of physicians of 
large experience, and they have uniformly answered that 
they had never known a patient to suffer the disease a 
second time." 

5. Age. — Age has some influence on the permission 
of the disease. Dr. Chancellor says: "I have most 
frequently found it to attack those who are in the meri- 
dian and full vigor of life : no case has come under my 
observation of its occurrence under twelve or over forty 
years of age." Dr. McLane writes: "The great ma- 
jority of cases has occurred with individuals between 
fifteen and thirty years of age. The youngest that 
came under my observation was five years, and the 
oldest sixty years." Dr. Brown has "never known the 
disease to occur in persons above the age of fifty, nor 
below the age of nine." He never saw but one case at 
fifty, and only ten at nine. Dr. Harris thinks " the age 
most liable from twenty to fifty." When epidemic, he 
has seen it "in children from five years to adults at 
sixty five." Dr. Hildreth says: "I have seen the 
disease well marked in a boy seven years of age; 






CAUSES — AGE. 9T 

another, in which the patient was fifty-eight ; but by far 
the greatest number occurs between the ages of twenty 
and thirty-five." Dr. Gholson writes : " Typhoid fever, 
in my experience, is confined to early and middle life. 
I have seen cases in children of three or four years of 
age ; have never seen a well marked-case of it in sub- 
jects over thirty years." Dr. Spitler says: "I have 
seen well developed cases in children between two and 
three years of age. The disease seldom attacks very 
aged persons, yet it sometimes does occur. In the fall 
of 1850, I attended P. H., who was in his sixty-ninth 
year, and suffered a most severe form of the disease, 
but convalesced so far as to be able to ride out on horse- 
back, when he relapsed and died. In the autumn of 
1851, I attended Mrs. S., then in her seventy-eighth 
year, who was also afflicted with a well-marked form of 
the disease. After many days this old lady recovered, 
and is now enjoying ordinary health." Dr. Cross has 
seen more of the disease "between the ages of fifteen 
and thirty-five." Dr. Payne says : " So far as my ex- 
perience extends, age has much to do in the permission 
of the disease, the young (say from six to twenty-five 
years of age) being much the most liable to take it. I 
do not recollect of having met with a case under the age 
of five, or older than sixty years." Dr. Blakey writes : 
" I have much more frequently met with the disease in 
persons between twenty and thirty years of age." Dr. 

9 



98 ENTERIC FEVER. 

Archer writes : " From fifteen to thirty furnish a ma- 
jority of the cases. I cannot remember meeting with a 
case at a more advanced age than forty-five. At this 
time I am attending a well-marked case in a child of 
three years, which has already lasted over twenty-five 
days. I have seen the disease once or twice in children 
of two years." Dr. Parker observes: "I think the dis- 
ease one of early life. Of eight patients, treated in the 
last sixty days, seven were between ten and twenty-five 
— the eighth forty-five years old. I do not recollect 
having treated a patient under six years, or over forty- 
five. A friend informs me that he is now treating a well- 
marked case, aged two and a half years." Dr. Faulk- 
ner remarks : "It belongs to the young. In a family 
with seventy slaves over twelve years of age, it was con- 
fined, with one exception, to those under twenty-one 
years old. I saw one case, in 1845, in a child under two 
years of age ; in 1845, one at fifty-six years ; this is my 
widest range." In Dr. Sutphin's experience, between 
the ages of eight and thirty furnish the greatest number 
of cases. The doctor writes : " I seldom meet with ty- 
phoid fever in persons over forty years of age. The 
oldest patient of the disease I have ever met with was 
upwards of sixty; the youngest twenty months old." 
Dr. Bland remarks : " Old persons are not so apt to take 
it as the young; though I have attended a number of 
persons over sixty years, and some over seventy. The 



CAUSES — AGE — SEX. 



99 



youngest person I have ever known to have the disease 
was an infant of fifteen months." Dr. Cullen says his 
experience in Virginia has not been extensive, but the 
cases that have fallen under his notice were those "be- 
tween fifteen and thirty years of age." Dr. JSTeff has 
witnessed more of the disease "between the ages of fif- 
teen and thirty-five." 

The annexed table will exhibit my own experience in 
one hundred and thirty cases, in which I paid attention 
to this point : — 





MALES. 




1 at 18 months. 




1 at 30 months. 




7 from 3 to 6 years. 


4 < 


< 6 to 9 


n 


3 < 


< 9 to 12 


tt 


6 < 


< 12 to 15 


tt 


8 < 


< 15 to 18 


tt 


3 < 


1 18 to 21 


tt 


13 < 


< 21 to 25 


a 


12 ' 


< 25 to 30 


tt 


4 < 


< 30 to 35 


tt 


3 < 


< 35 to 40 


a 


4 < 


< 40 to 50 


tt 


3 < 


< 50 to 60 


a 



71 



FEMALES. 


1 at 18 months. 


2 from 


3 to 6 years 


4 " 


6 to 9 " 


3 " 


9 to 12 " 


9 " 


12 to 15 « 


5 " 


15 to 18 « 


8 " 


18 to 21 " 


11 " 


21 to 25 " 


7 " 


25 to 30 " 


2 « 


30 to 35 " 


2 « 


35 to 40 " 


3 " 


40 to 45 " 


1 " 


50 to 60 " 


1 " 


60 to 65 " 



6. Sex. — From the above it is also seen that the ma- 
jority is in favor of males. This, however, has not been 



100 ENTERIC FEVER. 

constant, and I look upon the result as entirely acci- 
dental. Dr. James Jackson thinks the disease occurs 
oftenest among males. Among children, Barthez and 
Rilliet found a majority of males. In Taupin's cases 
there was a like result. Nathan Smith did not notice a 
balance of liability in favor of either sex.* 

7. Exposure. — Exposure to cold, excesses in the man- 
ner of living, may have some influence in the produc- 
tion of the disease ; but according to my own observa- 
tion, the large majority of patients are taken sick of 
the disease in the midst of full health. 

8. Recency of Residence. — Strangers coming into a 
district of country where the disease exists, and remain- 
ing a time, are particularly liable to be seized. Several 
instances of this kind have fallen under my notice. 

9. Race. — I am not aware that the slave population 
is more obnoxious to the disease than the whites, 
after excepting the advantages in its production which 
would accrue, in either race, from large assembling in 
small and ill-ventilated houses, which is sometimes the 
case on farms where a large number of blacks are 
worked. 

* Bartlett's Treatise on Fevers. 



CHAPTER VI. 

DURATION, AND COMPLICATIONS. 

1. The duration of enteric fever varies considerably 
in different cases, and under different circumstances. 
Dr. Bland writes: "I do not recollect having known a 
case to commence getting well in less than seven days. 
The longest duration of the disease, in my experience, 
was sixty-three days. I think the average duration may 
be set down at twenty-one days." Dr. Hildreth thinks 
" the average to be about twenty-six days." According 
to Dr. Harris's experience, "the duration varies from five 
to seven weeks." Dr. Archer writes: "The duration, 
in the large majority, varies between twenty-one and 
twenty-eight days. I have treated some cases which 
convalesced in eight days ; others, not until after several 
weeks." Dr. Payne thinks the average to be "about 
three weeks." Dr. McLane says : " In regular cases the 
average duration is twenty-one days." Dr. Brown re- 
marks : " The average duration of those who recovered, 
was thirty-two days ; of my fatal cases, ten days." Dr. 
Gholson says "its average duration is about three 

9* (101) 



102 ENTERIC FEVER. 

weeks." Dr. Spitler writes : " The duration of typhoid 
fever differs widely in different cases. I do not remem- 
ber ever to have seen a well-developed case of the dis- 
ease recover under twelve days. It more frequently 
continues twenty or thirty days. I hare known some 
cases of unusual persistence — for example, seventy-five 
days." Dr. Cross says: "Between twenty and thirty 
days furnish the duration in a large majority." Dr. 
Parker observes : " I have never witnessed a case the 
duration of which exceeded ninety days : nor do I re- 
member to have seen a patient get well under a fortnight. 
It is sometimes rather difficult to say when a patient is 
really well of the disease. I have frequently ceased to 
visit patients who, nevertheless, were not fit for business 
for two or three weeks afterwards." Dr. Faulkner says 
" slow continued fever is its most appropriate name, in 
many cases. Its duration is from three to six weeks." 
Dr. Cullen says : " Duration generally from three to six 
weeks." Dr. Sutphin writes : " The average duration, 
I should think, might be put dovn at fifteen days." 

In estimating its duration I have dated the first ex- 
treme of the period to be measured at the time patients 
become unable to pursue their accustomed exercise, and 
take to their beds ; the other extreme, with the cessa- 
tion of the febrile symptoms, the return of the appetite, 
and the ability to take solid food. It is proper to re- 
mark, however, that the date at which a patient, suffer- 



DUKATION. 103 

ing from enteric fever, may take to bed, will not, in 
every instance, be the date of the fully-developed dis- 
ease, but generally it is the case. " Walking cases," as 
they are called, are sometimes met with. I have known 
several patients suffering from the disease, who did not 
take to their beds for more than an hour or two at a 
time during the day, throughout the entire course of the 
disease, but wandered from place to place, the subjects 
of remark. In one such case, the patient was delirious 
for several days, and on this account his peregrinations 
about the streets were of particular notice. 

Reckoning as above proposed, the duration of sixty- 
four cases of the mild form of enteric fever was ac- 
cording to the annexed table :■ — 

MALES. 

In 2 cases the duration was 9 days, 

2 cases the duration was 10 

2 cases the duration was 12 

3 cases the duration was 13 

6 cases the duration was 14 

7 cases the duration was 15 

1 case the duration was 16 

6 cases the duration was 17 

5 cases the duration was. 18 

34 

FEMALES. 

In 1 case the duration was... 9 days. 

1 case the duration was 10 " 



104 ENTERIC FEVER. 

In 3 cases the duration was 12 days. 

1 case the duration was 13 

5 cases the duration was 14 

9 cases the duration was 15 

5 cases the duration was 17 

2 cases the duration was 18 

2 cases the duration was 23 

1 case the duration was 25 

30 

From the above it will be seen that a majority of the 
cases of this form terminated between the thirteenth 
and eighteenth days. 

The duration of the intermediate form, like its kin- 
dred, is not always the same. But to be understood : I 
said in an early chapter that a case of this form, the in- 
termediate, may not run a longer course than one in 
which the disease was mild throughout, i.e. a case mild 
in its character at first, may, after the lapse of several 
days, become aggravated, and present the severer class 
of symptoms described, and end in convalescence as 
soon as one that did not partake of this increase of se- 
verity. Therefore, in speaking of the duration of the 
intermediate form, it will be remembered that I include 
the whole time, from the date of the first development 
of the fever to the establishment of convalescence. 

The subjoined table will exhibit the duration of 
thirty-two cases passing into this form : — 



DURATION. 105 

MALES. 

In 1 case the duration was 15 days. 

2 cases the duration was 16 " 

3 cases the duration was 18 " 

3 cases the duration was 20 " 

3 cases the duration was 23 " 

2 cases the duration was 25 " 

1 case the duration was 31 " 

2 cases the duration was * 32 " 

1 case the duration was 40 " 

18 

FEMALES. 

In 1 case the duration was 17 days. 

4 cases the duration was 18 " 

2 cases the duration was 20 " 

2 cases the duration was 23 " 

1 case the duration was 25 " 

2 cases the duration was 28 " 

1 case the duration was 35 " 

1 case the duration was 48 " 

14 



The duration of twenty-five cases of the malignant 
form, the result of the existence first of the milder 
forms, was according to the following table : — - 



MALES. 

In 1 case the duration was 12 

3 cases the duration was 18 

1 case the duration was 23 

1 case the duration was 25 



106 ENTERIC FEVER. 

In G cases the duration was 28 days. 

1 case the duration was 30 " 

1 case the duration was 31 " 

14 

FEMALES. 

In 2 cases the duration was 15 days. 

1 case the duration was 18 " 

1 case the duration was 21 " 

2 cases the duration was 26 " 

2 cases the duration was 28 " 

2 cases the duration was 31 " 

1 case the duration was 35 " 

11 

Among these twenty-five cases were nine fatal cases, 
the duration of which the following table shows : — 

MALES. 

In 1 case the duration was 23 days. 

1 case the duration was 25 " 

4 cases the duration was 28 " 

1 case the duration was 30 " 

7 

FEMALES. 

In 1 case the duration was 26 days. 

1 case the duration was 28 " 

2 

The duration of nine cases assuming a malignant 
character from the beginning, is seen in the annexed 
table : — 



COMPLICATIONS. 107 

MALES. 

In 2 cases the duration was 15 days. 

1 case the duration was 18* " 

1 case the duration was 26 " 

1 case the duration was 60 " 

5 

FEMALES. 

In 2 cases the duration was 12 days. 

1 case the duration was -.. 18 " 

1 case the duration was 23* " 

4 

2. Complications. — Enteric fever is occasionally 
complicated with other diseases ; with some in the be- 
ginning, with others, and more often, not until an ad- 
vanced stage of the case. The earliest complications 
are with bilious-remittent fever and acute pneumonia. 
That bilious-remittent fever and enteric fever are 
sometimes closely commingled in miasmatic districts, 
the preceding pages indubitably show ; and so intimate is 
this blending of types, that it is not until the way has 
been cautiously felt that it can be determined which of 
the influences at work is foremost. 

The complication with acute pneumonia I have seen 
in two instances. One patient recovered. In the fatal 
case hemorrhage from the bowels ensued on the twelfth 

* Fatal. 



108 ENTERIC FEVER. 

day, the patient dying on the eighteenth day. At a 
late stage of the disease this complication is of more 
common occurrence, preceded by the most frequent of 
all complications, bronchitis. It is needless to mention 
the signs indicative of the springing up of these inter- 
current inflammations. 

Pleurisy is sometimes met with during the progress 
of enteric fever. I have met. with one or two such 
cases. 

Erysipelas is not unfrequently observed to attack 
patients suffering from the disease. In a case included 
in the table of fatal cases, of twenty-three days' dura- 
tion, erysipelas attacked the ear on the evening of the 
twenty-first day of the disease, which spread rapidly 
over the head and neck, killing the patient by the 
twenty-third day. 

The most fearful of the accidental inflammations is 
peritonitis, the result of perforation, and occurs some- 
times when least expected. "Its occurrence," observes 
Dr. Bartlett, "is marked by the sudden supervention of 
acute pain in the abdomen. This pain comes on, all at 
once, with no premonitory symptoms, with nothing in 
the condition of the patient to account for it ; and the 
suffering which it occasions is excessive. The access of 
the pain is frequently accompanied by chills ; the abdo- 
men becomes rapidly and acutely tender on pressure, 
and, if it was not so before, hard and tympanitic. The 



COMPLICATIONS — PERITONITIS. 109 

pulse is quick and compressed. An instantaneous 
change takes place in the physiognomy of the patient. 
The countenance is expressive of intense suffering; the 
features are pinched and cadaverous; and the face is 
covered with a profuse sweat. There is a constant and 
urgent desire for cold drinks. Nausea and vomiting 
are present soon after the inflammation has com- 
menced; the matter ejected from the stomach is of a 
grass-green color, and it continues to be thrown up to 
the last moment of life. Notwithstanding the con- 
stancy and the intensity of the distress, the patient pre- 
serves the same position, lying upon his back, and 
dreading every moment that may add to the pain and 
tenderness of the abdomen. Such, in most cases, is the 
formidable array of symptoms which indicate the oc- 
currence and mark the progress of this fatal complica- 
tion. Occasionally they are more obscure, and this 
peritoneal inflammation, like the fever itself, is, to a 
certain extent, latent. It is exceedingly rare, however, 
that there can be any difficulty in ascertaining its exist- 
ence. Death usually takes place in from one to three 
days after the occurrence of the perforation."* 

* Treatise on Fevers, pp. Ill, 112. 
10 



CHAPTER VII. 

TERMINATIONS, AND SEQUELiE. 

1. Convalescence. — The period occupied in convales- 
cence is of variable length. In a few cases, the passage 
to health is rapid. In the larger number of cases, it is 
slow and gradual; and sometimes the period thus occu- 
pied equals the duration of the disease. The return to 
health, in some instances, is so severely interrupted by 
unpleasant symptoms growing out of the irregular per- 
formance of the enfeebled functions, that what is gained 
at one period seems to be lost at another; and the case 
becomes more troublesome, and the prognosis even more 
unfavorable, perhaps, than during the height of the dis- 
ease. These drawbacks generally consist of irregularity 
of the appetite, which at one time is tolerably sharp, at 
another, requires stimulation; copious night-sweats; 
bowels either too loose or too costive ; frequency of the 
pulse, with increased heat of skin, restlessness, wakeful- 
ness, etc. 

The signs of convalescence are these: cleaning of 
the tongue, if it has been coated, or if red and dry, it is 
moist, and covered with a thin whitish fur ; reduction of 
(110) 



CONVALESCENCE. Ill 

the frequency of the pulse ; moisture of the skin ; in- 
creased quantity of urine discharged ; in place of wake- 
fulness, delirium, twitchings of the tendons, etc., the pa- 
tient is disposed to refreshing rest ; tympanitis gradually 
diminishes ; the discharges from the bowels are less fre- 
quent and of greater consistence; gradual increase of 
appetite ; and shrunken features. So marked is the 
emaciation of convalescence, sometimes, that the pa- 
tient's look is ghastly. How often do doctors receive 
the following reply, on announcing to the friends of the 
patient that convalescence has begun? "He may be 
better, doctor, but indeed, he does not look so : see how 
pale and how much more badly he looks now than he 
did two days ago!" 

Ordinarily, this emaciated look is not of long dura- 
tion. As the functions assume their wonted activity, 
the features swell out to their normal limits, and some- 
times a degree of fleshiness ensues, and becomes per- 
manent far beyond that of previous health. More 
generally, after the lapse of a few months any increase 
of flesh, beyond the accustomed point, subsides. In a 
word, the patient "is himself again," with the exception 
of the loss, may be, of a luxuriant suit of hair, which 
requires several months for its reproduction. 

Another fact I mention. It is possible for convales- 
cence to be interrupted by a return of the disease. In 
my experience true relapses have not often occurred. I 



112 ENTERIC FEVER. 

have met with but one such case. The patient, a fe- 
male, suffered a mild form of the disease, the duration 
of which was twelve days, and convalescence progressed 
rapidly for several days, when she committed an impro- 
priety in diet, that caused a return of the disease in a 
grave form, and confinement to bed for twenty-eight 
days. 

2. Death. — All patients do not die in the same man- 
ner. There are several modes of death, and the import- 
ance of studying attentively the "tendency" to this or 
that mode, not only on the appearance of an epidemic, 
but in each individual case, cannot be too strongly incul- 
cated; because it is only by the attainment of this 
knowledge that a successful practice can be instituted. 

Death by ancemia is caused by a want of the due sup- 
ply of blood to the heart. In death by asthenia there 
is no deficiency of supply, but a failure of the contrac- 
tile power of the heart. In death by asphyxia or 
apnoea, there is a stoppage of the entrance of air into 
the lungs. In death by coma, the only difference in the 
cause from that of apnoea being this : in death by apnoea, 
the chemical functions of the lungs cease first, and then 
the circulation of venous blood through the arteries sus- 
pends the sensibility; whereas, in death by coma, the 
sensibility ceases first, and in consequence of this the 
movements of the thorax are arrested, as well as the 



DEATH. 113 

chemical functions of the lungs. Thus the circulation 
of venous blood through the arteries is in one case the 
cause, in the other the effect of the cessation of animal 
life.* To these Dr. Williams adds another, "necrcemia, 
or death beginning with the blood,"' an example of 
which is frequently afforded in the termination of the 
disease under consideration. It is indicated when pete- 
chia and vibices make their appearance, by the occur- 
rence of more extensive hemorrhages in internal parts, 
the increased fluidity of the blood, and its tendency to 
pass into decomposition. f 

Death beginning at the heart, as existing by itself, is 
not common ; but is usually complicated with one or both 
of the two other modes. I have seen a few cases in 
which there was no pulmonary obstruction, nor was the 
mind at all clouded even up to the latest moment of life. 
The symptoms tending to death by asthenia are simply 
those of debility, which have been narrated in a previous 
chapter. I may be allowed to reiterate the following : 
a small thread-like pulse; position constantly on the 
back, with the inclination to slip toward the foot of the 
bed ; involuntary discharges of fasces and urine ; sharp- 
ening of the features ; the eyes sunken, filmy, and half- 
closed ; the temples and cheeks hollow ; the ears 

* Tanner's Clinical Med., p. 76. 

f Williams's Principles of Med., p. 416. 

10* 



114 ENTERIC FEVER. 

shriveled and retracted ; the skin shrunken and pale, or 
of a greenish, livid, or leaden hue; falling of the jaw; 
cold sweating on different parts of the surface ; when, at 
last, the heart stops and death is complete ! This mode 
of death is most often observed in those cases in which 
diarrhoea has been troublesome, and followed by hemor- 
rhage, and occurs in protracted cases of the disease. 

Death by asphyxia or apncea is more frequent than 
by asthenia, and is often combined with coma. The 
symptoms denoting the "tendency to death" by apnoea 
are easy of detection. Among the first is a noticeable 
quickness of respiration, and more or less dyspnoea, 
which cannot be wholly accounted for by the degree of 
fever and the state of the pulse; but if we apply "the 
educated ear" to the chest, the cause is explained — 
there is a commencing pneumonia, and it may kill, though 
there be none of the ordinary symptoms — cough, rust- 
colored sputa, or pain. How death by apnoea partakes 
also of coma is simple enough. Owing to the diminished 
capacity of the lungs for arterializing the blood, the ve- 
nous blood, instead of acquiring in its circuit through 
the lungs the qualities of arterial blood, is returned to 
the left side of the heart, and thence distributed over the 
system, still loaded with the matters which should have 
been exhaled, or revived by contact with the air. The 
blood, thus unfit for a healthy supply, is carried to the 
brain, where it destroys voluntary motion, sense, and 



DEATH. 115 

general sensibility, and induces coma; "it impairs even 
the excited movements of the respiratory muscles, thus 
allowing the lungs, the pulmonary artery, and the right 
side of the heart, to become gorged with blood — the last- 
named organ, receiving through the coronary arteries so 
imperfect a stimulus, soon loses its power of contracting, 
and death ensues."* 

The most common mode of death begins in the head, 
by coma. Delirium comes on, the patient lies half-con- 
scious, with eyelids partly closed, muttering disjointed 
sentences, and finally becomes completely insensible. 

Dr. Watson observes: "Coma may result from at 
least two different kinds of cause. One cause is pres- 
sure, which is mechanical; another, which is probably 
chemical, is the circulation of some noxious or narcotic 
substance (such as opium) in the blood. And there are, 
doubtless, many physical conditions of the nervous mass 
itself which are capable of arresting the cerebral func- 
tions and producing coma. To which kind of cause are 
we to ascribe the stupor that supervenes during the pro- 
gress of fever ? That is an interesting, and, in refer- 
ence to practice, an important question. Physicians 
have diligently attempted its solution by examining 
the dead brain. I cannot tell you how often I have 

* Stille's Elements of General Pathology, p. 140. 



116 ENTERIC FEVER. 

looked, and looked in vain, for some palpable disorgani- 
zation, or some effusion implying pressure. All who 
are familiar with the dead-house of a hospital are aware 
that this fruitless search for some physical explanation 
of the comatose state, after death by fever, is of very 
common occurrence. * * * Not only do we fail to 
discover, in many instances, any traces of inflamma- 
tion, upon inspecting the dead brain, but we find that 
during the life of the patient measures which would be 
likely to aggravate any inflammatory mischief — strong 
stimulants, for example, wine or brandy — do actually 
and obviously, in cases innumerable, relieve the coma- 
tose symptoms, and benefit the patient. The inference 
seems unavoidable, that the coma, in such cases, has 
some other cause than that mechanical pressure which 
arises sometimes from the effusion of fluid upon the sur- 
face of the brain, or within its ventricles, and that other 
cause is supplied by the poisoned blood."* 

3. Sequelce. — Upon this subject I have but one single 
remark to make. I have seen two instances of swelled 
leg and thigh like that which is incidental to parturient 
women. In one case the swelling came on during con- 
valescence ; in the other, not until some weeks after the 



* Watson's Lectures on Practice, p. 942. 



SEQUELS. 117 

patient was able to be out of bed. In the first-men- 
tioned case the swelling was accompanied with the most 
excessive tenderness, confined only to the upper third 
of the thigh. In the other case a slight degree of lame- 
ness was all that was complained of. 



CHAPTER VIII. 

DIAGNOSIS— MORTALITY AND PROGNOSIS— NATURE. 

1. Diagnosis. — Enteric fever is not always easily 
recognized in the beginning, although in the majority 
of instances it may be distinguished by the ex- 
perienced observer. In cases of sudden access, the 
diagnosis becomes sometimes very difficult, because 
chilliness, heat, thirst, quick pulse, pain in the head, 
back, and limbs, nausea, and vomiting, are the symp- 
toms which usher in not only other febrile affections, 
but the local phlegmasia generally, and hence the diffi- 
culty in the beginning in deciding upon the precise cha- 
racter of the attack. But two or three days will clear 
up all uncertainity and confirm the diagnosis; the symp- 
toms after that time, in an uncomplicated case, being 
wholly unlike those of any other febrile or local inflam- 
matory affection. 

The most characteristic symptoms have been already 
singled out, and their several degrees of importance en- 
larged upon. I have but little now to add except their 
enumeration. 

Coupled with the frequently slow and insidious mode 
(118) 



DIAGNOSIS. 119 

of attack, is headache, more or less severe ; diarrhoea, 
either from the beginning or soon afterwards, the dis- 
charges from the bowels being of watery consistence 
and of an ochry color ; expression of the countenance 
dull and apathetic ; obtuseness of the senses ; greatly 
impaired appetite ; occasional bleedings from the nose ; 
signal loss of muscular strength ; acceleration of the 
pulse, with an evening exacerbation of febrile heat ; 
cough and bronchial rales ; tympanitis ; gurgling on 
pressure over the right iliac quarter ; the rose-colored 
eruption ; dullness on percussion over the spleen ; som- 
nolency, or restlessness, vigilance, etc. 

If the case assume the intermediate grade of severity, 
increase of the above symptoms is superadded ; the 
tongue becomes dry, with a brown stripe down its mid- 
dle ; slight collection of sordes about the lips, gums, and 
teeth ; twitchings of the tendons ; deafness ; delirium ; 
discharges from the bowels more frequent, in color a 
little darker than before. The demand for cold drinks 
is less ; the patient seems insensible to his wants. In 
addition, the symptoms may go on to greater severity. 
The senses are more completely benumbed ; the patient 
lies constantly on his back, and inclined to slip down in 
the bed ; constant muttering of disjointed sentences ; 
picking at the bedclothes ; the tongue protruded slowly 
and tremblingly, and with a blackish crust upon its sur- 
face ; abdomen largely tympanitic ; incessant twitchings 



120 ENTERIC FEVER. 

of the tendons ; diarrhoea ; increased tendency to hemor- 
rhage from the nostrils, gums, and bowels ; heat of the 
surface unequally distributed, and its vitality so di- 
minished that the parts exposed to pressure become 
abraded, followed by sloughing. " These symptoms com- 
ing on without any obvious cause, occurring usually in a 
person under forty years of age, and referable to no 
local disease; increasing in severity, and terminating in 
death at an indefinite period after the eighth day, or 
gradually subsiding and disappearing one after another, 
and giving way to convalescence at an indefinite 
period after the fifteenth or twentieth day, mark most 
clearly and unquestionably, a disease wholly unlike any 
other."* 

The diseases with which enteric fever is most liable to 
be confounded are bilious-remittent fever, typhus fever, 
inflammation of the membranes of the brain, gastritis, 
mucous enteritis, and puerperal peritonitis. In mias- 
matic regions enteric fever is frequently blended with, 
and influenced by, the element of periodicity; and in 
some instances this blending is so complete that the real 
disease is, for several days, completely obscured. Dr. 
Robert A. Gholson, of the City of Petersburg, in a let- 
ter says: a This mixed type of fever usually makes its 
appearance among us with a chill, followed in the course 

* Bartlett's Treatise on Fevers, p. 125. 



DIAGNOSIS. 121 

of one or two days by another, or distinct remission. 
This paroxysmal character of the fever does not usually 
continue longer than the first week, when the continued 
or typhoid character is shown forth. In many cases 
the enteric lesions are not evinced until the latter stages 
of the disease ; no prominent meteorism, diarrhoea, etc. ; 
on the other hand, there is frequently torpor of the ab- 
dominal and intestinal secretions. Sooner or later, 
however, we have the usual symptoms characterizing 
the bowel lesions." 

In consequence of this commingling of types the 
diagnosis becomes sometimes very difficult, and espe- 
cially is this the case when the remittent type assumes 
low and protracted tendencies. 

Periodicity may exhibit itself at either extremity of 
enteric fever, during its access, or at its decline ; in the 
latter event, intermittent may result. 

Uncomplicated enteric fever may be distinguished 
from bilious-remittent fever — first, in the latter, by the 
more regular and decided remissions ; second, the bilious 
vomiting and jaundiced hue of the skin; third, its 
shorter duration, and its tendency to end in intermit- 
tent ; fourth, the entire absence of diarrhoea, epistaxis, 
dull and listless expression, tympanitis, the rose-colored 
spots, and that degree of prostration of muscular 
strength which mark enteric fever. Dissection con- 
firms the diagnosis. In remittent fever the stomach is 

11 



122 ENTERIC FEVER. 

more frequently inflamed ; greater discoloration of the 
liver ; the spleen less diseased ; and there is a total ab- 
sence of the characteristic change invariably found to 
accompany enteric fever in the elliptical plates and 
mesenteric glands. 

Enteric fever was long confounded with true typhus 
fever y and notwithstanding the conclusive researches of 
recent years, which have established beyond all cavil 
the dissimilarity of the two affections, the doctrine of 
identity is still adhered to by some writers. That the 
two diseases are essentially and fundamentally unlike 
each other in their nature, their symptoms, their patho- 
logy, and the treatment which they require, I think we 
have now the most abundant proof. For further infor- 
mation concerning the non-identity of typhoid and ty- 
phus, the reader is referred to the writings of Louis, 
Gerhard, Jackson, Jenner, Bartlett, and Wood. 

There are some diseases of the brain which, in cer- 
tain cases, may be difficult to distinguish from enteric 
fever, and when occurring in children the difficulty of 
diagnosis is greatly enhanced. In general, however, 
the presence or absence of diarrhoea, tympanitis, pros- 
tration of muscular strength, the rose-colored eruption, 
heaviness without delirium, will determine the true cha- 
racter of the affection. 

From gastritis, enteric fever may usually be distin- 
guished without much difficulty. So with mucous en- 



DIAGNOSIS. 123 

teritis. For the diagnostic symptoms of these affections 
the reader is referred to^the works of Wood and Watson 
on Practice. 

Our powers at accurate diagnosis may sometimes be 
heavily taxed to distinguish enteric fever from puer- 
peral peritonitis, especially when the symptoms of the 
latter bear the typhoidal relationship. The typhoidal 
state may attach to many diseases, and it is of the 
utmost importance that this relationship should be dis- 
tinguished from enteric fever proper. Puerperal peri- 
tonitis may present many of the most characteristic 
elements of enteric fever, such as rapid prostration of 
muscular strength, subsultus tendinum, diarrhoea, gur- 
gling on pressure over the right iliac quarter, tympani- 
tic distension of the abdomen, a dry, red, cracked, or 
blackish tongue, and wandering delirium. For the 
puerperal state this typhoidal condition seems to have a 
peculiar affinity, and should always be remembered in 
practice. My friend, Dr. William J. Bland, of Weston, 
Lewis County, in his letter heretofore referred to, says : 
"We have a disease following childbirth very much re- 
sembling enteric fever, but which is most unquestion- 
ably puerperal peritonitis. It usually commences on 
the second day after delivery, with chills, fever, purg- 
ing, great tympanitic distension of the abdomen, and 
with a pulse ranging from 110 to 180 per minute." 

I may in this place allude to a singular exhibition of 



124 ENTERIC FEVER. 

disease spoken of by Dr. Faulkner, in his letter of the 
date before mentioned. The doctor says : " In regard 
to our epidemic last year, I have an opinion of my own, 
in which I do not know that any of my brethren agree, 
that it was modified by an approaching epidemic erysi- 
pelas, which even then existed, unrecognized, in some 
neighborhoods. I saw in our neighborhood, in 1849, 
several cases, in different families, that I diagnosed as 
erysipelatous, and which terminated in effusion of puru- 
lent fluid in the peritoneal cavity. These had the 
general symptoms of typhoid fever ; and the case that 
gave me a clue to its pathology had a little erysipela- 
tous spot on tne face, which vanished in a day or two, 
when there was added to the other symptoms tenderness 
of the abdomen, which began soon to enlarge as in 
ascites, until there was a discharge, from the bowels, of 
a fluid resembling pus, but was most probably serum. 
In all, there were about three pints discharged in the 
course of twenty-four hours; and this was repeated 
about twice, at intervals of ten or twelve days, the ab- 
domen gradually enlarging each time until spontaneously 
tapped through the alimentary canal. This was the only 
case that I had charge of. Dr. Craddock had two cases 
under his care : one pursuing the same course as the one 
just described, with the exception of a less amount of 
discharge; in the other, the fluid finding an outlet 
through the abdominal parietes first, and then into the 



PROGNOSIS. 125 

bowels. A part of the fluid was thrown up by the 
stomach, and some discharged per anum. This patient 
was the sister of my patient, and was the only fatal 
case. In another family, Dr. Carrington had a similar 
case. Dr. C. tapped his patient for ascites, and was 
surprised to find, instead of a simple case of dropsy con- 
sequent on fever, a fluid of the same character as was 
exhibited in the other cases. This was to me a most re- 
markable batch of fever cases." 

Dr. Parker says he has "known one or two instances 
in which the patient, suffering from typhoid fever, was 
treated for chronic diarrhoea." 

2. Mortality and Prognosis. — I have already had 
occasion to allude to the rate of mortality of the disease. 
I now add that it varies with the character of the disease, 
in each epidemic visitation ; when endemic, according to 
the particular locality; in sporadic cases, it differs 
widely; and lastly, during some years, whether epide- 
mic, endemic, or sporadic, it varies materially from 
other years, and during like seasons. 

But while it is not an easy matter to arrive at any 
positive average result, on account of the variable in- 
fluences which operate in its production, march, and ter- 
mination, though it must be considered a grave disease, 
there is, perhaps, no other acute disease of like gravity, 
which, under proper management, more often terminates 

11* 



126 ENTERIC FEVER. 

in recovery. A considerable experience in its manage- 
ment has led me to consider no case, however mild it 
may seem, as free from danger : none so grave but that 
the patient may recover. 

While the prognosis, in any case, can very rarely be 
pronounced with absolute certainty, yet, in many in- 
stances, by carefully noting the degree of exasperation 
of certain symptoms as they arise, and comparing them 
with the amount of resistance offered by the state of the 
muscular strength, the result, if it cannot be pronounced 
with certainty, may be approximated. In other in- 
stances the utmost foresight and sagacity are useless 
in attempting to predict the result with any degree of 
confidence. In some cases, the physician's solicitude is 
peculiarly excited. For a time favorable symptoms will 
largely preponderate, flattering both the physician and 
friends of the patient with the approach of speedy con- 
valescence; at another time — and perhaps the change 
has been sudden — symptoms of an unfavorable charac- 
ter will assume the lead and continue for several hours 
only, or for several days: this mutation occurring 
several times, perhaps, before the case takes a final 
turn ; or the symptoms, favorable and unfavorable, may 
remain for several days so equally balanced that no 
one of the usual indices is left for reckoning as to the 
result. 

The mode of access would seem to have some influence 



PROGNOSIS. 127 

upon the subsequent character of the disease. Of forty- 
cases, in which the access was sudden, only one was 
fatal; while of ninety cases, in which the access was 
more or less gradual, ten were fatal. 

Headache is more severe, I think, in cases which run 
a grave course. 

Diarrhoea is a grave symptom in proportion to its 
urgency and continuance. No danger accrues from two 
or three discharges in the course of twenty-four hours : 
these do not seem to induce much prostration, and, I 
think, are of service; but when the number of dejec- 
tions, in the same space of time, amounts to more than 
five or six, then the case becomes of serious moment. I 
have never known a patient to die of the disease, whose 
stools did not exceed in number two or three in the 
course of a day or night. This is the experience also of 
many of my professional acquaintances, of whom I have 
inquired touching the subject. 

Hemorrhage, and involuntary discharges of faeces, 
occur only in very grave cases of the disease. Some- 
times hemorrhage by the bowels occurs as early as the 
twelfth day. Dr. McLane mentions this occurrence as 
having been quite frequent during an epidemic which he 
witnessed in 1853. I have myself, upon several occa- 
sions, witnessed the discharge of enormous quantities of 
blood from the bowels. In one instance, along with the 
excessive loss by the bowels, there was a continual oozing 



128 ENTERIC FEVER. 

of blood from the gums and nostrils ; and yet my pa- 
tient recovered. After such extensive losses a favorable 
termination is of rare occurrence. 

In cases of moderate hemorrhage from the bowels, I 
have seen the majority recover. After the occurrence 
of involuntary discharges of faeces the case does not 
always result in death ; but the majority of such cases 
terminate fatally. 

A pulse running above one hundred and thirty, when 
associated with grave symptoms, is unfavorable. In 
females, however, a pulse of one hundred and thirty is 
not more unfavorable than a pulse of one hundred and 
twenty in males. 

Delirium is of evil augury, in proportion to its early 
appearance, its kind, and degree of persistence. Mild 
delirium, occurring at night, or when the patient is alone, 
cannot, when considered by itself, be regarded as unfa- 
vorable ; but when associated with that perverted impres- 
sion which induces the patient to say that he is "not 
much sick," the chances are against his recovery. This 
feeling was manifested by a majority of my fatal cases. 
Wild and furious delirium occurs only in bad cases. In 
all cases the aphorism of Hippocrates is true: "When 
sleep puts an end to delirium it jls a good symptom." 

Cases without more or less obtuseness of the senses, 
are rarely met with, and it is only when the senses have 
become profoundly blunted that danger is to be appre- 






PROGNOSIS. 129 

hended. The opposite conditions — restlessness, watch- 
fulness, etc. — are far more unfavorable, and when pre- 
sent, in a well-marked form, other unfavorable symptoms 
are not far in the rear. 

I have already spoken of the prognostic value of the 
presence of deafness and epistaxis. 

The expression of the countenance is sometimes of 
significant importance. I am unable, however, to de- 
scribe its traits. There are some things occurring in 
our dealings with the sick, and which, to the experienced 
eye, are easily recognized, but which cannot always be 
imparted to others. This is exactly true as regards the 
expression of the countenance. We are quick to under- 
stand its meanings, but to tell how we understand is not 
always an easy matter. Suffice it to say, that if after 
the obliteration of an intelligent expression, for a 
greater or less length of time, the features brighten, and 
the patient pay some attention to things and persons 
about the chamber, and if, especially, he become solicit- 
ous for his own condition and safety, convalescence is 
at hand. 

In nine cases out of ten, there is more or less meteor- 
ism or tympanitic distension of the abdomen, and it be- 
comes unfavorable only when its increase is sudden, or 
when it becomes strongly marked. 

Spasmodic twitchings of the muscles are of serious 
significance. In mild cases of the disease they are some- 



130 ENTERIC FEVER. 

times observed; but always to a slight degree. When 
they are well marked danger is to be apprehended. One 
case only I have seen recover after they were pre- 
sent to the extent of epileptiform agitation of the whole 
body. 

In five of the eleven fatal cases, permanent rigidity 
of one of the limbs occurred. I have never known a 
case recover in which this symptom was present. Great 
difficulty of swallowing is, perhaps, of not less unfavor- 
able import. 

The condition of the tongue, if not of much import- 
ance when considered singly, may support the prognosis 
of other symptoms present. A dry, denuded, cracked, 
red, or blackish tongue generally accompanies grave 
conditions. A dry and red tongue is the usual compa- 
nion of severe disease within the bowels. 

The manner in which a patient respires is sometimes 
significant. If he breathes irregularly, and with a noisy 
hissing sound, and there are present other symptoms of 
gravity, the case is beyond all hope of recovery. In 
every such case which came under my observation death 
soon followed. 

Prostration of strength, when strongly marked in the 
beginning, is the sure precursor of a dangerous form of 
the disease. 

From my own experience I am not led to attach much 
importance to retention of urine. It occurred in only 
one of the fatal cases. 



PROGNOSIS. 131 

I have already spoken of the several intercurrent in- 
flammations most likely to spring up during the pro- 
gress of the disease. Of course their occurrence adds 
to its danger. The occurrence of erysipelas is full of 
evil augury. 

The presence of eschars accompanies low and dan- 
gerous conditions. They are of frequent occurrence 
among fatal cases. The same may be said of petechia 
and vibices, swelling and ulceration of the parotids. 

There is a condition of great danger frequently oc- 
curring in the course of the disease, and which has 
already received a considerable share of notice. I 
allude to that point in its progress when, after a seem- 
ing amelioration of many of the most troublesome 
symptoms, there is a sudden return ; the tongue again 
becomes red and dry; tympanitis occurs; diarrhoea is 
as urgent as before ; the skin becomes dry and parched ; 
there is delirium, with greatly accelerated arterial ac- 
tion. This exasperation of symptoms is of fearful im- 
port. 

There are some other points worthy of mention. 
Constitutional weakness does not seem to exert an un- 
favorable influence upon the course of the disease. 
When occurring in delicate subjects, it is most generally 
of mild character. But in young, robust persons, it 
often runs a rapid course, and frequently to death. 
The ages of the eleven fatal cases are as follows : — 



132 ENTERIC FEVER. 

Males. — 1 at fifty-two ; 1 at twenty-four ; 1 at twenty- 
three; 2 at eighteen; 1 at sixteen; 1 at fifteen; 1 at 
eleven years. 

Females. — 1 at forty-eight; 1 at twenty-one; 1 at 
eighteen years. 

This number is of course too small to insure a correct 
conclusion as to the degree of danger to be apprehended 
from age. 

I think, as a general rule, the disease is more fatal 
during the fall and winter months than at other seasons. 
Nine of the above cases occurred during the months of 
November and December. 

Recency of residence most certainly has some influ- 
ence upon the character of the disease. Strangers suf- 
fer more severely than acclimated residents. I have 
witnessed frequent examples confirming this assertion. 

I am not aware that the severity of the disease is at 
all influenced by difference in race. 

Pregnancy and lactation I have not found to have 
any material influence upon the character of the dis- 
ease. In the fourteen cases of the intermediate form 
pregnancy existed in five, the advance of which was 
two months in 2 ; three months in 1 ; four months in 
1 ; and six months in the remaining one. None of 
these miscarried. Among the cases of the malignant 
form, pregnancy existed in one, at an advance of two 
months. Miscarriage occurred on the tenth day of the 






NATURE. 133 

disease, and was not followed by any serious result. 
The patient began to improve by the twenty-first day. 

Of those who gave suck, two were of the mild, and 
one of the malignant form. In neither of the former 
was the child denied the breast. In the latter case, 
during the second week, the secretion of milk was en- 
tirely suspended ; the child was in consequence of it re- 
moved to a neighboring family, and not permitted its 
mother's breast for two months, when an abundant se- 
cretion again took place. 

Taking into account physiological differences, I have 
not seen the course of the disease in infancy and child- 
hood materially different from that in adults. In two 
cases, it has been seen, the disease appeared as early as 
the eighteenth month, (the mothers suffering from the 
disease at the same time ;) and from the third year up 
to the twelfth there were twenty-one cases. The dura- 
tion of the disease varied between nine and twenty-eight 
days. In the case of the last-mentioned duration, (aged 
eleven,) profuse hemorrhage from the bowels took place 
on the twenty-third day, followed by petechia, etc., ter- 
minating the life of the boy on the twenty-eighth. 

3. Nature. — Concerning the real nature of enteric 
fever much difference of opinion has existed ; and even 
at the present day, notwithstanding the uniform teach- 
ings derived from a careful examination of the changes 

12 



134 ENTERIC FEVER. 

found on dissection, opinions still differ. The new in- 
quirer, therefore, is left to select one of two courses : 
propose a new theory, or adhere, in part or in whole, to 
one or the other of those already promulgated. I 
choose to adopt that theory which supposes enteric fever 
to be the result of a specific poison, by some means in- 
troduced into the blood ; tiat in the attempt to elimi- 
nate this poison from the blood-current, the glands of 
the bowels, whose office is assigned to be that of eli- 
minating any putrescent accumulations from this fluid, 
become over-burdened, and thenceforth result in more 
or less change of structure ; that by such change the 
channels also, through which nutriment reaches the 
blood, are more or less obstructed ; that in consequence 
of this the blood becumes additionally depraved ; and 
that these causes, primary and secondary, acting to- 
gether, are capable of giving rise to the several condi- 
'tions characteristic of enteric fever. 



CHAPTER IX. 

TREATMENT. 

PREFATORY REMARKS. 

How far it is needful for the physician to interfere in 
the management of enteric fever, is a question of great 
importance. That too much may be, and often has been 
done, there can be no doubt. The bills of mortality 
from the disease, in the last few years, in many parts of 
the State, show favorably over former years ; and there 
is at present, perhaps, no other part of the ©ountry that 
equals Virginia in the frequency of the disease, in which 
the amount of recoveries, in a given number of cases, is 
exceeded. The present success, in the management of 
the disease, is not attributable to much medication, but 
the reverse of it, great care being taken that the little 
employed is well timed. The natural tendency of the 
disease is toward recovery, and many cases will end fa- 
vorably without medical treatment; and a goodly num- 
ber will get well in spite of a very bad treatment. From 
this fact, too often has resulted confidence in a course of 
practice which, nevertheless, may have lengthened the 
duration of the disease, and prolonged the period of 

(135) 



136 ENTERIC FEVER. 

convalescence. Here the old aphorism, that a desperate 
disease requires for its cure a desperate remedy, does 
not hold good ; but in place of it we may rely, tt> a con- 
siderable degree, upon the vis medicatrix naturce. But 
while it is important that we should guard ourselves 
against too much confidence in the use of medicines, we 
ought be careful lest we fall into the opposite extreme. 
Empiricism and skepticism are alike objectionable, and 
should be avoided, if we desire to be honest, while we 
are successful. To know how and when to interfere, 
constitutes the successful practice; and this knowledge, 
to a very great degree, can be obtained only by observ- 
ing closely at the bedside. The great mistake with very 
young practitioners, is their overweening confidence in 
medicines ; ^nd in no other disease is the temptation to 
be officious more powerful. To act with deliberation is 
the golden rule — " never permit the patient to be endan- 
gered by accidental suggestions at the bedside," but wait 
patiently the progress of any unfavorable symptom be- 
fore attempting to combat it with drugs. It is not at all 
uncommon for alarming symptoms suddenly to arise and 
soon subside; and this may occur several times in the 
progress of the disease ; and in nine cases out of ten, if 
we have withheld medicines, the patient is as well off, and 
may be better, than if they had been administered. 

It should be recollected that enteric fever is a disease 
which cannot be suddenly broken up by any method of 



TREATMENT — THERAPEUTICS. 137 

treatment, and to attempt to interrupt its progress by 
active measures is worse than folly: it would be risking 
the life of the patient. But while this is so, I think 
much may be done to moderate the violence of the 
disease, and, in many instances, a fatal termination 
averted. To be able to do the patient the greatest 
amount of good, requires close watching on the part of 
the physician. He should decide upon the "tendency" 
to this or that mode of death, and work accordingly, re- 
membering that "violence in therapeutics is never justi- 
fiable when moderation is adequate to the same good 
end."* 

There are other points of interest which should be 
constantly borne in mind in the management of the dis- 
ease. These are, the condition of the system at the 
time of the attack; the stage of the disease; age; sex, 
with its peculiarities; individual peculiarities; habits; 
previous disease ; and the tendency to complications. 
Without attention to all of these, no hope can be had of 
a successful practice. 

Therapeutic Processes and Agents. — The means 
proposed and employed by different practitioners, in the 
management of enteric fever, have been various and 
conflicting, each plan of treatment having had its advo- 
cates, and all supported by experience. Owing to the 
increased frequency of the disease in late years, this 

12* 



138 ENTERIC FEVER. 

subject has received additional importance ; able inves- 
tigators have been employed ; former extremes of treat- 
ment have been abandoned, or extensively modified; 
new agents have been discovered and successfully intro- 
duced ; old ones have been either entirely discarded, or 
only occasionally employed ; a simple or mild treatment 
has been instituted ; and an approximation to uniformity 
of practice is apparent, which was unknown prior to the 
works of Drs. Bartlett and Wood. 

At present the difference in treatment consists more 
in the period at which certain remedies should be 
administered, than in their choice. This is especially 
true of stimulants and tonics. Their usefulness is uni- 
formly acknowledged, but much difference of opinion 
prevails as to the proper time of their administration. 
This difference is perceptible when the practice in Vir- 
ginia is compared with the practice in some of the 
Northern States. There, quinia, beef, and brandy are 
resorted to freely in the beginning of the attack ; here, 
in Virginia, reliance is had first on diluents, and lastly 
on stimulants. It is probable that both parties are 
right, and that the difference in locality justifies and 
renders necessary this difference in treatment. 

I now come to speak of the several therapeutic pro- 
cesses and agents which are indorsed by the authority 
of experience, as of use, when timely employed, in mo- 
derating the violence of the disease, and in conducting 



TREATMENT — EMETICS. 139 

it to a favorable termination. I desire, however, to 
have it borne in mind that I am not in the habit, in 
every case, of employing all of the means to be here- 
after mentioned. Some of them I have rarely resorted 
to; but, by other practitioners, the same measures are 
more frequently employed, and I speak of them in 
order to present to the reader a fair expose of the sub- 
ject. I shall allude to them in the order of their most 
frequent use. 

1. Emetics. — By many practitioners, emetics are con- 
sidered of eminent service, when administered in the 
beginning of the disease ; and of their good effect, when 
thus employed, no little amount of evidence is on re- 
cord. This is the favorite practice with the venerable 
Dr. Jackson, of Boston, who is of opinion that it is not 
only capable of modifying the violence of the disease, 
but that in proportion to its early adoption, is the dura- 
tion of the disease diminished. He says: "Among 
those admitted to the hospital in the first two weeks of 
the disease, one hundred and fifty took emetics before 
or after admission; of these one hundred and fifty, 
thirteen died, being one in 11*53. 

"In the same period eighty were admitted who did 
not take emetics; of these ten died, being one in 8*00. 

"The difference is very striking. But of the one 
hundred and fifty who took emetics, some took them 



140 ENTERIC FEVER. 

earlier and some later in the disease. It has been 
thought that the earlier this and other active and de- 
pletory remedies are administered, the greater the bene- 
fit. See how far this is confirmed by the same report. 

"Fifty-nine entered the first week of the disease, and 
took emetics in that week; four of these died, being 
one in 14-75. 

" Thirty-one entered the same week, and did not take 
emetics ; of these three died, being one in 10-33. 

"Ninety-one entered the second week, and took eme- 
tics either before or after admission ; of these nine died, 
being one in 10*11. 

"Forty-eight entered the same week, and did not 
take emetics; of these seven died, being one in 6-85. 

"The advantage was on the side of those who took 
emetics; but more decided as to those who entered the 
first week, than as to those who entered the second. 
The last had not probably been so well nursed in the 
first week as the others. But also they had not, on an 
average, taken the emetic so early, and that, no doubt, 
made a difference in favor of those entering the first 
week. My own experience taught me long ago that 
emetics were most useful when taken within the first 
three days of the disease. This is confirmed by the 
hospital cases. It appears from the report that thirty- 
two patients took emetics within the first three days of 
the disease; of these one died — one in 32. 






TREATMENT — EMETICS. 141 

" Twenty-seven took emetics within the last four days 
of the first week ; of these three died, being one in nine. 

" Undoubtedly these last numbers, relative to those 
who took emetics in the last four days of the first week, 
are less favorable than would be found if the number 
was larger ; for the proportion of deaths is greater than 
in those who entered the second week, and took emetics, 
and of whom the larger part, no doubt, took their eme- 
tics at a later period of the disease than the above 
twenty-seven. 

" If now we inquire what was the effect or the dura- 
tion of the disease in those who took emetics and re- 
covered, it does not seem to have been much, if any- 
thing, to the advantage of those taking emetics later 
than the third day. But as to those who took emetics 
on either of the first three days, the benefit is un- 
equivocal. 

" Of those who took emetics on the first day of the 
disease, the average day of convalescence was the 14*66. 

" Of those who took emetics on the second day, the 
average day of convalescence was the 15*32. 

" Of those who took emetics on the third day, the 
average day of convalescence was the 16*46. 

"While of those who took emetics on the fourth, 
fifth, and sixth days of the disease, and recovered, the 
average day of convalescence was the 19*45. 

"It cannot surely be attributed to accident that these 



142 ENTERIC FEVER. 

results were so favorable to those who took emetics, 
among cases not selected, but taken as they came, 
through many successive years. But I feel assured that 
the result would have been found much more favorable, 
had all those who took emetics at an early period been 
properly managed afterwards. To the best success of 
this mode of treatment it is necessary that great care 
should be taken after the first relief from the emetic. 
However well the patient may seem, he should be 
treated as a sick man. The emetic should be followed 
by an active cathartic on the following day, unless it 
should itself have had a powerful operation on the 
bowels. Probably this was done in most of the cases. 
And then, for a week at least, however well the patient 
may appear, he should be restrained from all efforts of 
body or mind, and should be kept on a very moderate, 
bland, vegetable diet. Though the headache and pain 
in the back and limbs be removed, the pulse restored 
to natural frequency, the chills and heat subsided, 
still the liability to the disease remains. Therefore the 
disease is easily lighted up anew, and if great errors are 
committed, it may return in its full force and run 
through its entire period. All this I have learned long 
ago, in private practice." — Letters to a Young Physi- 
cian, p. 330. 

I have now presented the most carefully collected 
evidence in favor of the emetic plan to be found on re- 



TREATMENT — PURGATIVES. 143 

cord. Much additional testimony could be adduced, no 
doubt, of its usefulness in a certain class of cases, when 
employed early, in moderating the severity of the dis- 
ease. Whenever I have found present nausea and a 
bilious coating upon the tongue, I have been in the 
habit of administering an emetic, alone or in combina- 
tion with a cathartic, and have seen much good result. 
Sydenham remarked: "It is astonishing how it happens 
that a vomit, which does not produce either a large or a 
morbid discharge from the stomach, should so materially 
relieve the nausea, restlessness, anxiety, and furred 
tongue of the patient." 

At an advanced stage of the disease, sometimes eme- 
tics are not less useful. The stomach becomes nau- 
seated from vitiated secretion or other contents, and the 
patient lies so sickened that he is scarcely able to move, 
unless compelled in his unsuccessful attempt to vomit, 
and in these cases the exhibition of a mild emetic will 
afford marked relief, on which account it should not be 
omitted. To accomplish emesis at this period of the 
disease, the mildest articles should be used. Simple 
tepid water I have found sufficiently active in the ma- 
jority of instances. 

2. Purgatives — In the beginning of the disease, when 
diarrhoea is not present, the propriety of a brisk purga- 
tive is uniformly conceded. By common consent, also, 



144 ENTERIC FEVER. 

calomel is preferable from its more complete evacuation 
of the bowels ; "from its superior power of arousing the 
recuperative energies and counteracting the tendency 
to congestion, or relieving its incipient formation, as 
well as from its excellence in restoring or rectifying se- 
cretory action, not to mention other salutary effects." 
It may be given singly, or in combination with other 
purgative medicine, as rhubarb or jalap ; and* in cases 
where gastric disturbance is present, it may, with ex- 
cellent effect, be administered with a sufficient quantity 
of ipecacuanha to produce vomiting. When the bowels 
are spontaneously purged, as often happens, the hyd. 
cum. creta may be substituted for the calomel, and to 
which may be added a small quantity of the pulv. Do- 
veri, should pain of the bowels be complained of, and 
the disposition to stool frequent ; this to be followed in 
due time, if necessary, by a dose of castor oil, or of soda 
et pot. tart. Throughout the entire progress of the dis- 
ease, it is generally thought best that the bowels should 
be moved once or twice in the course of twenty- four 
hours, and if this do not occur naturally, laxatives 
should be administered. In the earlier stages of the 
disease, Seidlitz water is usually sufficient to accomplish 
a regular action of the bowels, while it is, perhaps, the 
most acceptable dose to the patient. Late in the dis- 
ease, regulation of the bowels is more properly managed 
by rhubarb and castor oil. But it sometimes happens 






TKEATMENT — PURGATIVES. 145 

that these means, notwithstanding their frequent use, 
fail to produce full evacuations, and the dejections are 
small, dark, and offensive. Here a full dose of senna 
infusion or other active medicine, is followed with good 
effect. In several instances I have seen the patient, 
after an apparent stand-still for several days, enter into 
convalescence almost immediately after the action of a 
full dose of senna. Such means are particularly ser- 
viceable when the stools are small and frequent, say 
three or four a day. It is of importance that attention 
be paid to the time for administering medicines to act 
on the bowels. The morning should be chosen, in order 
that their effects may be accomplished before night, and 
especially so as to avoid interfering with the usual 
opiate dose, to insure rest. A restless night should be 
avoided whenever possible. 

But there is another class of cases which require 
other means for the regulation of the bowels. Some- 
times the stomach is so irritable that ordinary aperients 
are rejected, and even increase the irritation; in such 
cases the bowels should be regulated by injections, 
by which the large intestines are unloaded, and the 
action of the upper part of the alimentary canal is as 
thoroughly promoted. • 

In that condition of the disease, when the tongue is 
dry, the skin parched, scanty urine, diarrhoea and tym- 
panitis, delirium or stupor, twitchings of the tendons, 

13 



146 ENTERIC FEVER. 

a small and weak pulse, the propriety of small closes of 
mercury, with a view to its specific effect, by some 
authorities is urged with no little emphasis. Dr. Wood 
says: "Under these circumstances I know of no remedy 
so effectual as mercury, given so as slightly to effect the 
gums. It is indicated by the general failure of the se- 
cretions, and the general languor of the vital functions. 
It is also indicated as an antiphlogistic remedy." In 
these conditions I have frequently given mercury, with 
a view to effect the gums, though I have but rarely 
witnessed the attainment of my object, until when it 
could not be thought serviceable, when the force of the 
poison was naturally expended, and convalescence be- 
gun. The readiness to take on the mercurial action is in 
proportion to the gravity of the disease. In the severer 
class of cases I have found it almost impossible to bring 
the patient under its specific influence, until after the 
turning-point of the disease had arrived, when, instead 
of a benefit, it was a disadvantage. But while this has 
been my experience, I do not reject as useless the em- 
ployment of small doses of mercury. In the conditions 
above specified they are of much service, though the 
gums are not affected ; and few cases occur in which an 
occasional pill of calomel or blue mass, conjoined with 
ipecacuanha and some preparation of opium, if the con- 
dition of the brain allow of the latter, may not be em- 
ployed with benefit. 



TREATMENT — BL OD-LETTING. 147 

3. Blood-letting. — General blood-letting is now very 
rarely practiced in enteric fever. Formerly the same 
caution and nice discernment now observed in its em- 
ployment was not exercised, and to this, more than from 
any other cause perhaps, may be attributed the very 
great increase in the number of recoveries in late years. 
In those cases which bear a severe character from the 
beginning, where headache is violent, increased sensi- 
bility to light and sound, the pulse full and strong, 
high fever, with a robust and plethoric habit, it may be 
proper to abstract a moderate quantity of blood from 
the arm ; but unless it is resorted to during the first two 
or three days of the disease, it had better be omitted. 
The state of the pulse is not an infallible sign of the ad- 
missibility or propriety of general blood-letting, and 
unless along with its full and bounding condition there 
are other and significant indications, its employment 
may so prostrate the patient as to cause him ultimately 
to sink under the disease. This uncertainty of reliance 
on the state of the pulse, in the choice of general bleed- 
ing, I have already adverted to, and I mention it again 
because it is important to be remembered. The local 
abstraction of blood, however, is of very great service, 
and there are but few cases to be met with in which it 
may not be beneficially employed. Cups are preferable 
from their more ready and easy use, and may be em- 
ployed wet or dry, according to the object to be at- 



148 ENTERIC FEVER. 

tained, and the degree of prostration present. In the 
early stage of the disease they may he applied for the 
removal or abatement of epigastric pain and tenderness; 
for the relief of headache, and other manifestations of 
strong determinations of blood to the brain ; for the re- 
moval of abdominal pain and tenderness. Subsequently 
they may be applied to the chest, for the relief of any 
pulmonary complication, and repeated according to the 
urgency of the case. The good to be derived from their 
application depends, to some degree, upon the time of 
their employment, the best time being when the skin is 
dry, and during an elevation of febrile excitement. 

4. Diaphoretics, etc. — The means proposed to influ- 
ence relaxation of the surface and the reduction of fe- 
brile heat are various, and more or less uncertain in 
their effects. The means most frequently employed 
with the view to these objects, are the neutral mixture, 
or effervescing draught ; the citrate, or acetate of am- 
monia; sweet spirits of nitre, and cold or tepid spong- 
ing ; the choice of these depending upon the circum- 
stances of the case, or the opinion of the practitioner. 
In the commencement of the disease the citrate of po- 
tassa is the article most generally chosen. This, in the 
form of the neutral mixture, or effervescing draught, 
may be administered every two or three hours during 
the day, when the skin is hot and dry ; and for a night 



TREATMENT — DIAPHORETICS. 149 

dose, when undue determination of blood to the head 
does not contraindicate it, the pulv. Doveri, with the 
addition of a small quantity of one of the salts of mor- 
phia, may be given to induce moisture and procure rest. 
By many valued authorities, when the stomach is 
quiet and diarrhoea not troublesome, a small quantity of 
tartar emetic is recommended to be added to the saline 
mixture; but while the stomach may be quiet I have 
noticed a marked susceptibility to the action of this 
medicine, and after witnessing both its good and bad 
effects, have thought that I served my patients best by 
withholding it altogether. When restlessness, wakeful- 
ness, twitchings of the tendons, etc., come on, there 
may be added to the mixture sweet spirits of nitre, and 
should this fail to produce quietude, the aqua camphor, 
Hoffman's anodyne, or opiates, if admissible, may be ad- 
ministered, in connection with the above remedies. In 
the severer forms of the disease a better article for in- 
ducing moisture is, perhaps, the spiritus mindereri. 
This is especially serviceable when irritability of the 
stomach exists, it being not only easily retained, but 
capable, frequently, of allaying irritability of this 
organ. It is also an excellent vehicle for the adminis- 
tration of other remedies. Besides its power to con- 
trol nervous irritability, camphor certainly possesses a 
marked tendency to produce diaphoresis, and without 
exciting the heart's action, and when combined with the 

13* 



150 ENTERIC FEVER. 

more decided agents, sometimes a happy effect is pro- 
duced. In cases in which the combination is allowable, 
(and in the large majority of cases it is allowable,) cam- 
phor, with Dover's powder, is an excellent combination 
for the purpose of producing moisture, and allaying any 
undue excitement of the nervous system. The veratrum 
viride is certainly, sometimes, a prompt and ' powerful 
diaphoretic. I regard it as of especial importance in 
the management of enteric fever. "When I come to 
speak of this agent as an arterial sedative, its diapho- 
retic tendency will be recurred to. 

To quench thirst, as well as to assist in cooling the 
surface, the mineral and vegetable acids may be added 
to the ordinary drinks. Those most acceptable to the 
patient are made with lemon, orange, and tamarind ; 
and on account of their acceptability, some caution is 
requisite to be given to the attendants, lest they be used 
to excess, and when the bowels are acting too freely. 

When diarrhoea is urgent, even simple unacidualated 
drinks should be restricted. As tiften happens in 
country practice, the vegetable fruits above named can- 
not be had, and in this case the mineral acids, such as 
the diluted sulphuric or nitric acid, may be employed, 
and, if the patient desire it, he may take into his mouth 
small particles of ice. The most effectual means of re- 
ducing the morbid heat are cold and tepid spongings. 
In the early stages of the disease cold water is generally 



TREATMENT — -DIAPHORETICS. 151 

most grateful to the feelings o^ the patient, and it may- 
be applied to the entire surface when the skin is uni- 
formly hot and dry. Ordinarily the application is made 
only to the face, temples, and extremities. In the 
severer forms of the disease, or when the patient is 
much prostrated, tepid sponging (from 87° to 97° Fah- 
renheit) is the more acceptable application, and may be 
employed when the heat of the surface is above the 
natural standard. Tepid water with vinegar, or even 
brandy-and-water, forms an excellent wash when the 
patient is much prostrated. Many times I have had 
the patient sponged from head to foot with warm 
brandy, very slightly diluted, and with the most gratify- 
ing results. 

For the abatement of headache, cold evaporating 
lotions may be employed. For wild and furious deli- 
rium, when coming on early in the attack, the cold 
douche will rarely fail to produce calmness, at least for 
a time ; and this may be resorted to several times if 
necessary. 

The admission of plenty of cool air into the sick-room 
is of great importance in the successful management of 
the disease. The bed and body linen should be changed 
daily if possible, but among the very poor this generally 
cannot be done. Their destitution, however, of the 
many little delicacies which are so grateful to the feel- 
ings and tastes of the sick, together with the ordinary 



152 ENTERIC FEVER. 

conveniences which belong to the sick-room, is fully 
compensated by the cool breezes which gain free and 
continual admission through their open and humble 
dwellings. 

5. Veratrum Viride. — During the past two or three 
years this agent has engaged much attention as a re- 
medy in enteric fever, and like all other newly intro- 
duced articles, it has had its advocates, opposers, and 
stigmatizers. By some authorities it has been declared 
the most decided and valuable arterial sedative of which 
we have any knowledge ; by others this property, if not 
wholly denied, has been thought uncertain ; and by 
others it has been charged with the tendency to cause 
abortion, and, therefore, pronounced unsafe in general 
practice. At present, however, it occupies no little pro- 
minence in the therapeutics of enteric fever. That it is 
capable of controlling the heart's action, and may be 
relied on, is a fact of which I am as well convinced as 
of any other established truth in medicine. How it 
produces its effect upon the pulse, whether by its action 
directly on the nerves governing the circulatory func- 
tion, or indirectly through a nauseant impression, is a 
matter of some difference of opinion. That it does fre- 
quently produce the most deadly nausea is true, but 1 
have also seen the pulse under its entire control without 
the least distress at the stomach being produced. A 



TREATMENT — VBRATRUM VIRIDE. 153 

professional friend, Dr. W. R. Kinkaid, of Burnersville, 
Barbour County, who suffers from a heart affection, in- 
forms me that he has frequently taken the veratrum 
viride in thirty and forty drop doses, and without the 
slightest disturbance of the stomach, the only sensation 
produced being a sensation of dizziness. 

One of the advantages this agent possesses over tartar 
emetic is, that it does not disturb the bowels, and this, if 
it were without other advantage, entitles it to a decided 
preference as a remedy in the management of enteric 
fever. Besides its signal property as an arterial seda- 
tive, it is capable of producing other excellent effects, to 
some of which attention has not been much directed. I 
allude more particularly to its diaphoretic tendency; 
and that it possesses this to a marked degree an experi- 
ence with the remedy during the past two and a half 
years in the management of this and other diseases, 
enables me to speak of its action with no little degree of 
confidence. In all proper cases of enteric fever, ac- 
cording to my own experience, it is a safe, reliable, and 
valuable adjuvant to other means employed for its ma- 
nagement. I have administered it to the young and to 
the aged, to the delicate and robust, in the pregnant 
state at all its periods, and have not had cause to regret 
its effect* The accusation brought against it^by Dr. 
Brown, of Georgia, that it is an abortive agent, and 
therefore its employment is unsafe in general practice, 



154 ENTERIC FEVER. 

is, I am persuaded, -wholly without just foundation. 
So far indeed from possessing a tendency to produce 
abortion, further experience may possibly establish 
that, in certain conditions, the veratrum viride may 
be beneficially employed for the purpose of defending 
the pregnant state. If my own experience does not 
directly contribute to establish this fact, it at least as- 
sists in proving the remedy free from the charge pre- 
ferred against it. As an apology for what is said, I 

offer the following case : Mrs. , aged thirty-six, of 

very weak habit, a sufferer from prolapsus uteri for ten 
years, the mother of seven children, aborted once at 
four months ; was taken sick of enteric fever, January 
1st, 1858; pregnant the eighth time at an advance of 
four and a half months. During the first week of the 
disease the pulse ranged between 110 and 115 per 
minute, and by the twelfth day it was running at 130. 
Along with this state of the pulse was restlessness, heat 
and dryness of skin, pain in the small of the back and 
abdomen, with a slight show of blood from the vagina. 
Being partially authorized, from previous experience, to 
regard the veratrum viride as of service for the relief of 
this condition, I determined to bring my patient under 
its full influence. I began with Norwood's tincture, at 
the dose^of five drops, and increased the quantity by 
two drops at each successive dose, every three hours, 
until the dose of eleven drops was reached, after which 



TREATMENT — VERATKUM VIRIDE. 155 

the pulse came down to 84, and the patient's condition" 
was much improved, being free from pain, the whole 
surface covered with a gentle perspiration, and all this 
with but very little accompanying nausea. To maintain 
this control of the symptoms the dose of five drops was 
ordered to be given every four hours. Under the in- 
fluence of this diminished dose, the pulse ranged pretty 
steadily, between 80 and 90, for the space of some forty 
hours ; but the nurse omitted the regular administration 
of the remedy, and a rapid circulation recurred, with 
restlessness and great heat of skin. Ten drops were 
now given, and the dose ordered to be increased as be- 
fore, and continued until its effects should be displayed. 
After the administration of a dose of seventeen drops, 
the pulse came down from 130 to 70 in the minute, ac- 
companied with relaxation of the surface, and a little 
increased nausea. To keep up this control eight drops 
were ordered to be repeated every four hours, and for 
several days the influence of the remedy was well sus- 
tained, the number of pulsations not exceeding 104 per 
minute. But it was again omitted, and this time oc- 
curred a pulse of 140, and of greatly reduced strength. 
The remedy was again pushed to the conquering dose, 
which was nineteen drops. The pulse came down to 
74, and brandy and morphia were required to relieve 
nausea, which this time was considerable. The remedy 
was continued in doses of eight drops, every four hours, 



156 ENTERIC FEVER. 

for several days, after which the dose was reduced to 
five drops, then to three drops, and in this dose it 
was continued more or less often for many days. The 
patient convalesced, went on to her full time, and was 
delivered of a healthy child. 

This case presents the strongest testimony I am able 
to offer in support of the non-abortive tendency of the 
veratrum viride; but it is not the only testimony I 
have. I have administered the remedy at all periods of 
pregnancy, and thus far have not observed the slighest 
excuse for the charge made against it by Dr. Brown. 
And I go a step farther and say, that in a certain class 
of cases, instead of the veratrum viride having a ten- 
dency to procure abortion, I think it may be success- 
fully employed to prevent this result. In the above 
narrated case, the telling doses were eleven, seventeen, 
and nineteen drops — the greatest quantities that I have 
found requisite to bring the pulse under control; and the 
remedy was more or less regularly persevered in for 
some twenty-eight days. 

A well-written review of the ideas advanced by Dr. 
Brown appeared in the December number of the Nash- 
ville Medical Journal for 1856, page 496, by Dr. R. 
E. Haughton, of Richmond, Indiana. Dr. Haughton 
says: "My own experience teaches me that, in low 
conditions, when the heart's action is feeble and rapid, 
this remedy may be used, reducing the number of beats, 



TREATMENT — VERATRUM VIRIDE. 157 

and as this is done the pulse becomes fuller and softer, 
while the extremities, which had been cold from defi- 
cient circulation, now become warm, and the shrunken 
skin again resuming its natural color, fullness, etc. 
The sedative then does not weaken the powers of life 
under such circumstances, but acts as a conservator of 
the life forces." Again he says: "I rely upon this 
medicine in the treatment of enteric fever more than 
any other one article, yet, when the indications require, 
I do not reject others ; and this is the experience of 
many of my professional friends who have tried it at my 
request." In proof of its non-abortive tendency, he 
writes: "I have used this remedy freely but carefully 
for the last three years, in cases of pregnancy in all its 
periods, having had no case of abortion, either from 
that or anything else, during the time of using it." 

While I declare my esteem of the virtues of the vera- 
trum viride, I am unwilling to acknowledge it a curative 
agent, or as even being necessary in every case of enteric 
fever; but I am willing to declare it a most valuable 
auxiliary, in many instances, to other recognized means, 
in moderating its violence, and in conducting it to a 
favorable termination. I do not think that we are 
authorized to believe that the disease can be suddenly 
interrupted by any method of treatment. But while 
this is so, much good may be accomplished by moderat- 
ing symptoms that cannot be wholly subdued, — in re- 

14 



158 ENTERIC FEVER. 

pairing dangerous complications incident to the disease, 
and toward aiding the flagging efforts of the vis medi- 
catrix naturae. Whenever thought proper to resort to 
the veratrum viride, with the view to its full effect, I 
have begun by giving five or six drops of the saturated 
tincture, in a little sweetened water, and repeated the 
dose every three hours (increasing the quantity by two 
drops at each successive dose) until the pulse was 
brought down to, or below, the natural standard. I 
have never had reason to think that any material benefit 
was to be gained by pressing the pulse below sixty-five 
or seventy, and have been satisfied with the result when 
the number of pulsations was reduced to between 
seventy and eighty per minute. 

After the telling dose has been reached, I have gene- 
rally been able to perpetuate its influence by the admi- 
nistration of from two to eight drops every three or four 
hours. Ordinarily, it rarely requires the fourth dose to 
effect complete mastery of the pulse. In one instance, 
a female, I found the first dose, of five drops, sufficient 
to bring a pulse of one hundred and thirty down to 
seventy; and complete control was maintained by the 
use of two drops every three hours. When excessive 
nausea follows its administration, it may be promptly 
relieved by a little sweetened brandy and morphia. 

In the management of fever patients, when the vera- 
trum was employed, I have noticed that, as a general 



TKEATMENT — A STK INGENT S. 159 

rule, the appetite was better sustained, and the thirst 
less urgent than when not used. I have never noticed 
that it had the slightest effect on the bowels. For much 
important information concerning the properties and 
uses of the veratrum viride, the reader is referred to 
the North American Medic o-Chirurgical Review, vol. 
ii. No. 5, p. 914. 

6. Astringents. — Medicines of this class are of much 
importance in the management of the disease. The 
articles most frequently employed are opium, tannin, 
creosote, benzoin, acetate of lead, and argenti nitras. 
The manner in which opium produces constipation has 
been differently explained. It cannot be said to pos- 
sess any of the characters of a general astringent; 
and yet, says Headland, there is no other astringent 
like it in its action on the bowels. By this authority, 
its action, as an astringent, is attributed to its general 
paralyzing influence on muscular fibre, "both of the 
voluntary and involuntary kind, but particularly of the 
latter." And he adds: "The only reasonable attempt 
that can be made to explain the action of opium in pro- 
ducing constipation, is by a reference to this, its para- 
lyzing influence on the coat of the bowel, taken in con- 
junction with the torpid condition of the general system 
and suspension of the animal functions, produced by 



160 EXT ERIC FEVER. 

the secondary action of this narcotic on the nervous 
forces."* 

To control diarrhoea, when sanguineous determination 
to the brain does not forbid of its employment, opium, 
alone or in combination with ipecacuanha and potassa, 
such as Dover's powder, may be administered two or three 
times a day, if necessary. Should the stools indicate 
too much acidity, prepared chalk may be added to the 
Dover's powder. When hemorrhage from the bowels 
occurs, the free use of opium and the sugar of lead is 
uniformly considered the best means for its arrest ; and 
when taken along with vinegar, to prevent the acetate 
from being converted into the carbonate of lead, it may 
be used with perfect safety. From one grain to two 
grains of opium, with from two to six grains of the ace- 
tate, may be given every fourth hour, washed down with 
a draught containing a quantity of distilled vinegar. 

To arrest hemorrhage from the gums and nostrils, 
when attention is required, tannin, creosote, or benzoin 
may be employed. f These may be used in solution; 
and when for the purpose of arresting hemorrhage from 
the gums, the article chosen may be taken into the 
mouth and retained for a few minutes, and repeated ac- 

* Action of Medicines, p. 348. 

f On the use of benzoin, in epistaxis, Dr. Fordyce Barker. 
See Am. Med. Monthly, vol. ix. p. 124. 



TREATMENT — FOMENTATIONS. 161 

cording to the urgency of the case. For epistaxis they 
may be injected into the nostrils, or dossils of lint, sa- 
turated with the solution, introduced, and renewed from 
time to time until the flow has ceased. Should hema- 
turia occur, much benefit sometimes follows the adminis- 
tration of a solution of gallic acid, or infusion of buchu. 
In the late stages of the disease, when there is a dry 
tongue and wasting diarrhoea, the nitrate of silver is 
recommended. This was the favorite remedy of the late 
Dr. J. K. Mitchell, of Philadelphia; and on account of 
its use by so valued an authority, it has been more or 
less extensively employed throughout the country, and 
there are many physicians to be found who heartily in- 
dorse all that its author claimed for the remedy. That 
in many instances its action is prompt in correcting 
diarrhoea and tympanitis, and in producing a change of 
the condition of the tongue, there can be no doubt. 
When opium was admissible, I have generally preferred 
to administer the nitrate according to the annexed for- 
mula : — 

I£. — Pil. opii officinalis, 3ss ; 
Argent nitratis, grs. viij. 
M. Fiat mass in pil. xxx divid. qua rum sumat unam terve in 
die. 

7. Fomentations, etc. — Fomentations may be re- 
garded as a species of local bathing, and are of great 

14* 



162 ENTERIC FEVEB. 

service in the management of enteric fever. Their use 
is for the relief of abdominal pain and tenderness. 
Flannel cloths wrung out of boiling water, and applied 
as hot as can be borne, form the best fomentations ; but 
on account of their unavoidable tendency to wet the 
bed and body clothes, poultices are most generally pre- 
ferred. Clean and pleasant applications, but objection- 
able for the same reasons attached to hot fomentations 
with flannel, are wet compresses, which are advocated 
with much earnestness by Dr. Huss, of Stockholm. 
The ordinary applications, which are, perhaps, as good 
as any, are made of corn-meal mush, and applied warm 
as can be borne. When they succeed cupping upon the 
abdomen, much good often results from their employ- 
ment. A favorite application, with me, is a large 
warm cake made of batter of buckwheat flour. This is 
easily prepared, nice when prepared, and retains warmth 
for a considerable time, — above all, it is very light. As 
fast as one becomes cold another should be applied. 
"When much tenderness exists, mustard flour may be 
sprinkled upon the cake before applying it, or a mus- 
tard cataplasm may at once be applied. To derive the 
full benefit of poultices, they should be regularly ap- 
plied; and it will usually require the services of one 
person to attend to these. Hot pediluvia may also be 
frequently resorted to with benefit. In any stage of 
the disease they are not objectionable, and frequently 
become absolutely necessary. 



TREATMENT — BLISTERS. 163 

8. Blisters. — The propriety of blisters in enteric 
fever has been variously estimated. According to my 
own observation, they are powerful both for good and 
evil. When delirium or stupor exists, a blister timely 
applied to the occiput may save the patient. The same 
may be said frequently to result from their use when 
applied to the chest. Many times I have seen a pneu- 
monic complication, which threatened the speedy death 
of the patient, vanish after the drawing of a large blis- 
ter. When applied to the abdomen late in the disease, 
I think they are of doubtful propriety. Occasionally I 
have thought that I observed good to result from their 
use ; but in other instances I have witnessed bad conse- 
quences follow, and on this account sorely regretted 
their use. Their tendency to become gangrenous, when 
applied upon the abdomen, should always be remem- 
bered, and whenever employed upon this region great 
caution should be observed. When the skin has become 
fully reddened, the blister has been on long enough, and 
should be followed by a light bread and milk poultice. 
When the blister has been drawn by the poultice, the 
serum should be let out and the same dressings conti- 
nued. If, instead of healing kindly, they should assume 
the appearance of an eating sore, oxide of zinc oint- 
ment, spread tolerably thick on lint or a piece of ordi- 
nary cloth, may be applied, over which is laid a light 
poultice. When the sore becomes gangrenous, a solu- 



164 ENTERIC FEVER. 

tion of chlorinated soda, or a solution of chlorinated 
potassa should be added to the dressings; but greatest 
reliance is to be had on the internal use of quinia, wine, 
and milk-punch. When opium is allowable, it forms a 
valuable stimulant and one of peculiar benefit, in the 
condition above mentioned, and on this account should 
not be omitted. 

9. Oil of Turpentine. — To Dr. Wood belongs the 
credit of having brought to the attention of the profes- 
sion the value of this agent as a remedy in the manage- 
ment of enteric fever; and that it is useful, and some- 
times eminently so, when employed according to the 
indications pointed out in his writings, much testimony 
could be adduced. By his works on Practice and Thera- 
peutics, this great and good man has done a special and 
lasting kindness to American practitioners; and in no in- 
stance is the truth of this remark more exactly in point 
than in his directions concerning the management of the 
disease under consideration. His account, though short, 
is invaluable to every practitioner ; and if, by the publi- 
cation of these pages, it is shown that his observations 
concerning the disease are indorsed by country expe- 
rience, that his precepts for its management are success- 
fully practiced by his brethren in Virginia, this alone 
will be an apology for their appearance. I cannot do 



TREATMENT — OIL OF TURPENTINE. 165 

better than to give Dr. Wood's own language concerning 
the use and benefits of the oil of turpentine. He says : 
" Though the oil may be of some use as a mere stimu- 
lant in this disease, it is, in that respect, of but com- 
paratively little value, and cannot be depended on to the 
exclusion of wine-whey, carbonate of ammonia, and 
nutritious aliment, in low conditions of the fever. But 
the oil will accomplish what these cannot. It acts most 
happily in stimulating the diseased patches of Peyer's 
glands, and the isolated glands of the same kind, 
whereby the softened and disorganized matter is more 
readily thrown off, and the ulcerated surfaces disposed 
to heal when they might otherwise be unable to do so. 
The remedy, therefore, is to be given at the period 
during which the discharge of the softened matter is 
going on, and ulcers are forming or in existence. This 
is usually, I believe, about the middle, or toward the 
close of the second week. Before this time I count 
upon no material service from the oil. It is now that 
the tongue becomes dry ; and the occurrence of the dry 
state of the tongue, in a decided degree, is the signal 
for commencing with the use of the remedy. I give it 
usually in doses of ten drops every two hours, but some- 
times increase to fifteen or twenty drops. At the end 
of twenty-four, or at the furthest, of forty-eight hours, 
there may very generally be seen a return of moisture, 
with a white fur on the surface of the tongue at the 



166 EXTEEIC FEYEE. 

sides, for its whole length, leaving the surface in the 
middle still dry and often cracked. "With this amend- 
ment, there is often also a diminution of the tympanitis, 
a cooler and moister skin, and a less frequent pulse. 
The same change goes on till the whole tongue becomes 
moist, and covered usually with a whitish fur, which 
then gradually disappears, commencing from the tip and 
edges. Sometimes, even when there has been no dry- 
ness of the tongue in the case, I have seen the oil to 
act favorably in ameliorating the symptoms; and fre- 
quently, when the disease has appeared to linger in its 
advanced stages, and, though not severe, to show a per- 
verse disposition to hang on to the patient, I have seen 
it almost immediately enter into convalescence under 
the use of the remedy. Again, when the case is marked 
in its progress by the cleaning of the tongue by flakes 
or in patches, leaving a red and smooth surface, or if 
deprived of the outer layer of the epithelium and pa- 
pillae, and when the surface of the tongue, whether com- 
pletely or only partially cleaned, instead of remaining 
moist as it does in favorable cases, becomes very dry, 
with an aggravation of the general symptoms, I take it 
for granted that there has been a corresponding un- 
favorable change in the intestinal ulceration, indicating 
the use of the oil. It is precisely under these circum- 
stances that, previously to my original use of the oil, I 
had seen a majority of the cases that came under my 



TREATMENT — OIL OF TURPENTINE. 167 

notice prove fatal; and, since the use of it, only two. 
I do not claim for the oil any specific power over enteric 
fever. It will not prevent death from intercurrent 
pneumonia, or meningitis, or various other sources of 
mischief; but I do think, as the result, too, of great ex- 
perience in the disease, that so far as the mere affection 
of the intestinal glands and its direct consequences are 
concerned, it will vastly diminish the chances of a fatal 
issue. The reason why, in the special condition of the 
tongue last described, the favorable effects of the remedy 
may be almost certainly calculated on, is that at the 
commencement of the cleaning process, the proper idio- 
pathic disease has about run its course, and would 
almost certainly end well, but for an unfavorable change 
in the condition of the ulcerated surfaces; and what- 
ever, therefore, will favor the healing of these, will, in 
all probability, secure a favorable termination. I have 
been more particular in this account of the use of the 
oil of turpentine in enteric fever, because I have great 
confidence in the efficiency of the remedy myself, and 
wish to prevail on others to use it by showing the 
grounds of this confidence, and pointing out the precise 
circumstances under which, according to my experience, 
it should be employed." — Treatise on Therapeutics, vol. 
i. pp. 563-5. 

I have employed the oil of turpentine quite often, 
and sometimes with good effect. A case has just passed 



168 ENTERIC FEVER. 

through my hands, in which the remedy was unusually 
prompt in relieving the dry tongue, etc., and the patient 
entered into convalescence without any other remedial 
resort. The case came under my care with the state of 
symptoms described above, — and fifteen drops every 
three hours made quite a new man out of my patient in 
the course of a day's time. But while I, with profound 
pleasure, bear testimony to the virtues of the oil, it is 
not my only reliance for the conditions so particularly 
pointed out by Dr. Wood. In cases admitting the free 
exhibition of ojrium, I have found this remedy equally 
beneficial in subduing the symptoms for which the tur- 
pentine is mainly prescribed. I allude to the use of 
solid opium, which, in my hands, has been so effectual 
that I have been unwilling to exchange it for any other 
means. I am not, however, authorized in believing that 
my proportion of favorable cases has exceeded that of 
some of my country co-laborers, who place greatest 
reliance on the oil of turpentine; yet I think I am 
warranted in saying that my success has, at least, been 
equal to theirs. In many instances I have administered 
the turpentine and opium conjointly, and when thus 
employed, sometimes have had reason to think that 
the good effect of both articles was increased. Where 
opium is admissible, I am in the habit of giving from a 
half to two grains every four or six hours. Under the 
use of this remedy I have seen a red and dry tongue 



TREATMENT — CHLORATE OF POTASH. 169 

become moist, and coat itself over with a thin whitish 
fur; the pulse become less frequent, and increase in 
volume; subsultus diminish; delirium calmed; the skin 
relaxed and gently perspiring; diarrhoea and tympani- 
tis diminish ; and refreshing rest take the place of wake- 
fulness and great uneasiness. When thought proper to 
administer the opium and turpentine together, the same 
dose of opium may be added to every other dose of the 
oil emulsion. I have, indeed, been many times highly 
pleased with the effect of this combination. 

10. Chlorate of Potash. — This agent is certainly of 
much service in the management of enteric fever. I 
have been in the habit of employing it in almost every 
case of the disease that has fallen under my care for the 
last five years. When sordes begin to form about the 
lips, gums, and teeth, I am in the habit of ordering it in 
weak solution as a constant drink. It is an excellent 
vehicle for the administration of the veratrum viride, 
and may be used then according to the formula pro- 
prosed by Dr. Taliaferro: ly. — Chlorate potash, satu- 
rated solution, fgiv; tinct. verat. viride, 5ss. M. Of this 
the patient is to take a tablespoonful every three hours 
during the day. 

11. Tonics and Stimulants. — The resort to tonics 
and stimulants is not necessary in every case of enteric 

15 



170 ENTERIC FEVER. 

fever, though they are not on this account the less im- 
portant; sometimes they become essential to the saving 
of the patient. In their employment the nicest dis- 
crimination is very often requisite. When untimely re- 
sorted to they are as potent for evil as they are for good 
when timely employed. If the disease prevail as an 
epidemic, a careful study of its particular tendency will 
guide materially in the decision. Without attention to 
the epidemic constitution, by which we learn the "ten- 
dency" to death, fatal mistakes are likely to be made in 
the use of these remedies. 

During some epidemics, the conditions that require to 
be met by stimulants and tonics present at an early 
period of the disease. More commonly, however, they 
are not essential until during the second or third week 
of grave cases. In deciding upon their admissibility the 
state of the pulse, the skin, and the muscular strength, 
demand particular consideration. If the pulse be soft 
and compressible, the skin cool and moist, and the 
strength considerably prostrated, the indications for a 
stimulant are pretty surely made out. If, in addition to 
the above, there are twitchings of the tendons, a dry, 
brown or red tongue, dark sordes about the lips, gums, 
and teeth, low muttering, delirium, and, perhaps, purple 
spots scattered upon the surface, the demand for stimu- 
lants is urgent, and are required to be administered 
freely. But there is another condition, in some points 



ETC. " 171 

differing from the above, in which stimulants are some- 
times eminently useful. Instead of the skin being 
moist, it is somewhat hot and dry; and the pulse, be- 
sides being weak, is very frequent. Here a stimulant, 
cautiously administered, is often productive of a marked 
alleviation of the symptoms. In the employment of 
these means it is best to begin with the mildest articles* 
and keep the patient under close surveillance during 
their trial, so that should they fail to accomplish a salu- 
tary purpose, actual mischief may be prevented. If, 
after the administration of tonics and stimulants, the 
pulse diminish in frequency and increase in volume, the 
skin lose its heat and dryness, (if these have existed,) 
and become moist, the delirium is calmed and the atten- 
tion more easily fixed, muscular twitchings abate or dis- 
appear, the countenance brighten, and instead of pre- 
vious wakefulness or stupor, the patient is disposed to 
healthy sleep, the remedy is acting well, and should be 
continued. If, instead of this amelioration, the symp- 
toms become exasperated, the remedy should at once be 
omitted. To quiet nervous irritation, sweet spirits of 
nitre, Hoffman's anodyne, camphor, etc., may be em- 
ployed. The usefulness of camphor in the treatment is 
everywhere acknowledged, and when administered in 
conjunction with opium, its influence in quieting nervous 
agitation, restlessness, and inducing quiet sleep, is often 
most happily displayed. Indeed, it is sometimes sur- 



172 ENTERIC FEVER. 

prising how quickly a moderate dose of camphor and 
opium will quiet delirium and other troublesome symp- 
toms. In the section on diaphoretics these remedies 
were spoken of. To the list of medicines of this class 
may now be added serpentaria, quinia, wine, carbonate 
of ammonia, brandy, and opium. Much discussion 
has been had concerning the amount of reliance to be 
placed in quinia as a remedy in the treatment. With 
some practitioners it is the chief reliance from first to 
last ; by others its early employment is strongly depre- 
cated. In districts where periodic fevers also prevail, 
the quinia plan finds its greatest number of advocates, 
and it is at least possible that this confidence may some- 
times have been the result of errors in diagnosis, and 
that instead of the disease, so benefited by the free and 
early use of quinia, being in every instance, as it has been 
called, genuine enteric or typhoid fever, it was remittent 
fever with very low tendencies. In sections of Virginia 
where periodical fevers are now almost entirely unknown, 
but in which enteric fever in its genuine form is to be met 
with more or less extensively every year, the early use 
of quinia in the treatment finds but few advocates; but 
during the stage of prostration, then it becomes a 
favorite resort, and the effect sometimes produced in 
improving the appetite and strength is almost magical. 
When employed it should be commenced with in small 
doses, say two or three grains two or three times a day, 



TKEATMENT — STIMULANTS, ETC. 173 

and may be given alone or in combination with wine, oil 
of turpentine, etc., as the case may require. Should it 
produce nausea and vomiting, or increase the frequency 
of the pulse and the heat of the skin, it must be omit- 
ted. In very low and prostrate conditions, injections of 
qumia are occasionally of great service. I have known 
a wasting diarrhoea, which had resisted all of the ordi- 
nary means for its arrest, speedily checked by an injec- 
tion composed of about twenty grains of quinia and 
three or four ounces of tolerably sharp vinegar, this to 
be repeated at intervals of three or four hours. During 
the stage of exhaustion, animal broths, wine, carbonate 
of ammonia, and even pure brandy, sometimes, are re- 
quired. When wine is employed it may be administered 
in the form of wine-whey, prepared by adding one part 
of good wine to two parts of boiling milk, and straining 
after coagulation, of which a wineglassful or less may 
be given once in two or three hours. As a diffusible 
stimulant, carbonate of ammonia is well adapted to low 
conditions. The following formula, from Dr. Wood, is 
the one I am in the habit of employing : 1^. — Ammo- 
nise carbonat. gij; acacise pulv. sacch. alb., aa^ij; aq. 
menth. p. vel aq. fluv. f Svj. M. From a teaspoonful to 
a tablespoonful to be taken every hour or two, diluted 
with a little water. — JPrac. Med., vol. i. p. 335, note. 

Pure brandy sometimes becomes absolutely essential. 
An agreeable mode for its administration is in the form 

15* 



174 ENTERIC FEVER. 

of milk-punch. In those cases in which extreme pros- 
tration comes on suddenly, generally the result of large 
losses of blood by hemorrhage, the internal exhibition 
of brandy, sulphuric ether etc. are not the only means 
of resort; and if, along with the debility, the skin is cool 
and of a bluish color, hot brandy should be rubbed upon 
the surface, and if this fail to excite sufficient stimula- 
tion, hot spirits of turpentine, etc. should be briskly 
rubbed upon the extremities, or, if necessary, mustard 
plasters may be applied to the wrists and ankles. In 
the employment of sinapisms upon the extremities, care 
should be taken that they are not suffered to remain on 
longer than is merely sufficient to produce slight red- 
dening of the skin. From inattention to this, I have 
once or twice seen sloughing of the surfaces to which 
they had been applied. 

The value of opium as a stimulant in enteric fever cannot' 
be too highly estimated ; but it is a sharp, two-edged sword, 
and of such energy that if does not fulfill a restorative 
intention, it will surely endanger the life of the patient. 
Its value depends therefore, on the discrimination with 
which it is employed. Not only is nice discrimination 
requisite in deciding on the cases which may be bene- 
fited by its use, but also in regulating the dose. Dr. 
Sandwith remarks: " There is no instance in the whole 
range of practical medicine more imperatively demand- 
ing a sure diagnosis, and our warrant to prescribe it 



ETC. 175 

hinges on our ability to ascertain precisely that condi- 
tion of the brain which alone will admit of its safe 
employment." He further remarks: " The class of 
cases of purely irritable states of the brain is to be dis- 
criminated, as Dr. Latham shows, less by any series of 
symptoms flowing from the brain than from the single 
symptom of a state of protracted wakefulness. Nor 
is the wakefulness pathognomonic, per se, but to warrant 
the use of opium, it must occur in combination with an 
irritable state of the nervous system."* 

Dr. Latham, in his remarks upon the subject, says: 
"I have seen the sensorial affections incident to fever, 
which require opium for their cure, manifest themselves 
in another form. There has been high vascular action 
from the first, and large depletion has been required to 
subdue it and to guard particular organs, and especially 
the brain, from injury. Under such treatment, all has 
gone on successfully, and the patient has reached the 
point of convalescence, with a soft pulse, a cleaning 
tongue, no pain, and refreshing sleep for two or three 
days; when suddenly — the tongue, the pulse, and all 
other circumstances continuing the same— some strange- 
ness of manner has arisen, and then the wildest deli- 
rium, and then the unrestrained passage of the evacua- 

* Half- Yearly Abstract of the Med. Sciences, No. xvii. 



176 ENTERIC FEVER. 

tions. I have known the transition from such a state of 
convalescence to such a state of peril take place in a 
few hours ; and I have known the patient again brought 
back to a state of convalescence in twenty-four hours 
by a moderate dose of opium. This is a rare form of 
disease, but one in which, when it does occur, opium is 
eminently indicated."* 

"When injudiciously administered, as in sthenic cere- 
bral excitement, or in the improper arrest of diarrhoea 
in certain states of fever, it has been observed to pro- 
duce phrenitis, epilepsy, and coma." In its employ- 
ment we are to be guided by the degree of sensorial 
excitement. "Simple wakefulness," observes Dr. La- 
tham, "may be gently lulled to sleep by a few drops of 
laudanum, but wild delirium requires to be mastered and 
(as it were) forced into repose by a much larger dose." 
"Wild delirium, and long wakefulness, and a circulation 
weak and fluttering, seem to call for a considerable dose 
of opium. Yet, withal, there is a certain jerk in the 
pulse, so that we cannot help suspecting that the blood- 
vessels have something to do with the sensorial excite- 
ment. Under such circumstances I have certainly seen 
twenty minims of laudanum produce tranquil sleep, from 
which the patient has awoke quite a new man; but I 

* Dr. F. M. Latham on the use of Opium in Fevers ; London 
Med. Gazette, 1852, vol. x. p. 10. 



TREATMENT — STIMULANTS, ETC. 177 

have also seen the same quantity produce a fatal coma, 
from which he has never been roused." To avoid 
"striking a heavy blow in the dark," Dr. Latham 
advises that the remedy should be commenced with in 
small doses at intervals of an hour or two, "so as to 
stop short of actual mischief at the first glimpse of its 
approach, or be led by a plain earnest of benefit to push 
the remedy to its full and consummate effect." Dr. 
Sandwith observes: "Great and marvelous, therefore, 
as are the virtues of opium in a variety of diseases, and 
admirable as are its soothing qualities in several of the 
forms of cerebral disorder in fever itself, yet let no man 
venture to prescribe it for the latter (whether in large or 
small doses) in the dark or at random."* 

For much valuable information concerning the uses 
and advantages to be derived from tonics and stimulants 
in fever, and especially as relating to the use of sulphate 
of quinia and wine, the reader is referred to the paper 
of Dr. Wilks "On the treatment of Fever," published 
originally in Guy's Hospital Reports, vol. i., 1855, and 
copied in No. xxiii. of Hanking' s Half- Yearly Abstract 
of the Medical Sciences, p. 28. 

The remedies most frequently employed to relieve 
muscular spasms are camphor, musk, and valerian. Of 
these I have found valerian to be as effectual as. any* 

* Association Med. Journal, Jan. 1, 1853. 



178 ENTERIC FEVER. 

other article of the class. I mean the pulverized vale- 
rian, and which may be given in teaspoonful doses every 
hour or two. 

Dietetic Management. — Strict attention to the 
diet of the sick is not less important in the successful 
management of the disease. The following instructions 
from Dr. Wood, embraced in few words, are all that is 
essential to be observed concerning it: "In the early 
stages it should be very light, consisting chiefly of liquid 
substances, which may also answer the purposes of 
drink. Solutions of gum Arabic, barley-water, rice- 
water, toast and water, weak solutions of tapioca, sago, 
or arrow-root, very weak gruels of oatmeal or Indian- 
meal, molasses and water, vegetable jellies mixed with 
water, and other similar preparations may be succes- 
sively, or interchangeably employed; and the patient 
may be allowed, if he desire it, to swallow the juice of 
sweet grapes and oranges, taking care to reject the solid 
portions of these fruits. Cold lemonade or orangeade, 
carbonic acid water, and pure iced-water in moderation, 
may also be used as drinks. At a more advanced 
period, in the second week, for example, when the 
symptoms of debility begin to show themselves, it will 
be necessary to support the strength by a more nutri- 
tive diet, which, however, should not be stimulating. 
Preparations of tapioca, sago, or arrow-root of a nearly 



DIETETIC MANAGEMENT. 179 

gelatinous consistence, thick gruels, or panada, may now 
be given, flavored with nutmeg or other spice, and sugar, 
and not unfrequently with wine. It will often be de- 
sirable to give these in certain quantities, at certain in- 
tervals, so as to insure that enough is taken. I have 
generally been in the habit of directing a wineglassful 
to be given every two or three hours, or less frequently, 
according to the apparent strength of the patient. A 
cup of tea may also be allowed, with dry toast or water- 
cracker, morning and evening. Still further on in this 
stage of the disease, milk in small quantities frequently 
repeated, will often be found to suit the case admirably 
well. A tablespoonful of it may be given every hour or 
two through the day; and, if the stomach be irritable, 
it may very properly be associated with an equal quan- 
tity of lime-water. In the last, or prostrate stage, it is 
proper that the diet should not only be nutritive, but 
also stimulating. Animal broths or jellies may now be 
given ; and, in the lowest cases, it is necessary to resort 
to egg beat up with wine, milk-punch, and the essence of 
beef or mutton. 

"Throughout the whole case, the greatest attention 
should be paid to cleanliness and ventilation ; and, when 
the atmosphere cannot be sufficiently purified by these 
means, as sometimes happens when many patients are 
crowded together, recourse may be had to the corrective 
influence of chlorine." — JPrae. Med., vol. i. p. 336. 



180 ENTERIC FEVER. 

Management of Complications. — Enteric fever may 
become suddenly complicated with local inflammation. 
The brain and the lungs are particularly liable to 
become involved, and very frequently these are the 
immediate cause of death. The careful study of the 
symptoms flowing from the brain cannot be too strongly 
impressed. Delirium, it is to be remembered, is not in 
every case the result of inflammation within the cra- 
nium. Dr. Tweedie remarks: "There is a form of low 
delirium in fever which requires to be distinguished from 
that arising from inflammation of the brain or its mem- 
branes. It arises from some peculiar condition of the 
brain with which we are unacquainted, and may be distin- 
guished from the acute form of febrile delirium by the 
palor of the face, the bloodless appearance of the con- 
junctiva, the softness of the pulse, the cool state of the 
scalp, and the absence of muscular twitchings. It oc- 
curs chiefly in feeble and exhausted habits, and fre- 
quently in persons who have suffered large losses of 
blood in the treatment. In other instances it may be 
traced to intestinal irritation, or some of those lesions in 
the bowels which so frequently accompany continued 
fever. This sympathetic delirium is not relieved, but 
invariably increased by the abstraction of blood. It is 
best managed by small quantities of nourishment and 
opiates, with a blister to the nape." 55 " 

* Cyclo. Prac. Med., article Fever, vol. ii. p. 191. 



MANAGEMENT OF COMPLICATIONS. 181 

When the symptoms indicate the existence of inflam- 
matory action within the encephalon, such as pain in the 
head, flushing of the face, hot skin, thirst, rapid pulse, 
acute delirium, watchfulness, etc., means must be imme- 
diately adopted for its arrest. Should it follow close 
upon the attack, a moderate general bleeding may be 
practiced, followed by cups to the temples and nucha, 
cold water or pounded ice to the scalp, and small doses of 
mercury and ipecacuanha. At an advanced stage of the 
disease, the greatest reliance must be had on the effect 
of the cold douche; this to be repeated as often as an 
exasperation of the symptoms occurs, and followed by 
cupping and a blister to the nape of the neck and occi- 
put. . Concerning the employment of blisters to the 
head, for cerebral inflammation, Dr. Tweedie remarks: 
"The too common practice of. blistering the head in 
such instances, before the excitement is diminished by 
blood-letting, is reprehensible. The application of blis- 
ters to the head in fever should be confined to those 
cases in which there is danger of the inflammatory 
action terminating in effusion, or to that particular state 
of the brain in inflammation, which, though there be an 
effusion, is attended by coma. Hence when, notwith- 
standing depleting measures have been judiciously ap- 
plied, the patient becomes drowsy and insensible to sur- 
rounding objects, except when roused, a blister may be 
advantageously applied to the occiput, while an iced 

16 



182 ENTERIC FEVER. 

evaporating lotion is kept on the forehead, and the 
system brought under the influence of mercury con- 
joined with digitalis and squill, so as to promote the 
action of the kidneys."* 

Bronchitis is the most frequent of the pulmonary 
complications; and unless the chest be frequently 
ausculted, a grave character of inflammation may escape 
notice. When delirium or stupor supervenes, the fre- 
quent employment of the ear becomes absolutely neces- 
sary, as by it we not only detect the existence of in- 
flammatory mischief, but the degree of its intensity. 
When this complication is in its incipient stage, a few 
cups to the chest, and demulcents to allay cough, to- 
gether with the general plan of treatment, is usually 
adequate for its arrest; but when it has been fully set 
up, more active interference is necessary. Here free 
cupping is requisite, and should be followed by warm 
poultices of Indian-meal mush, or cakes of buckwheat 
flour, and an occasional mustard cataplasm, and a blister 
if necessary. 

Prior to the introduction of the veratrum viride, tar- 
trate of antimony was the chief reliance for the relief 
of pneumonitis ; and sometimes this remedy was admi- 
nistered in very large doses, though the pneumonia oc- 
curred at a late stage of the disease. At present, 

* Cyclo. Prac. Med., article Fever ; vol. ii. p. 191. 



MANAGEMENT OF COMPLICATIONS. 183 

however, the number of advocates of the use of this 
agent, in any condition of enteric fever, is considerably 
diminished, the veratrum viride having been found 
equally efficacious, without effecting the least disturb- 
ance of the bowels. Along with the use of the vera- 
trum viride may be employed warm poultices upon 
the chest; occasional cuppings, wet or dry; small doses 
of calomel, ipecacuanha and morphia, or of Dover's p ow- 
der, and, if necessary, blistering and stimulating expec- 
torants. 

Sometimes there is a sudden supervention of acute 
pleuritic pain. When this occurs, cups should be ap- 
plied over the painful spot, and if relief does not soon 
follow, a blister should be drawn. 

Erysipelas is best treated by penciling the inflamed 
surface with tr. iodine or tr. mur. ferri, and the internal 
exhibition of the latter remedy in doses of from ten to 
sixty drops every few hours. 

When peritonitis occurs, opium is the only remedy 
which is at all capable of affording any hope of relief. 
It should be administered in large doses, and perfect 
rest enjoined, at the same time rejecting every article 
of food or medicine which, in the least, may have the 
tendency to disturb the tranquillity of the bowels. In 
those cases in which there is a blending with the bilious- 
remittent type, Dr. Grholson writes: "If called in the 
commencement of such attacks, I usually commence the 



184 ENTERIC FEVER. 

treatment with a mild mercurial cathartic,' and as soon 
as the bowels are by this means evacuated, commence 
with the sulphate of quinia, without much regard to the 
fever, but if it should run high, cold water is to 
be plentifully allowed as drinks, and the same applied 
to the surface, by sponging; and sometimes the cold 
douche becomes necessary. The quinia is continued for 
several days, or until the fever loses its periodical 
feature, or we are satisfied that enough of the remedy 
has been administered to lead to this result, if, indeed, 
it can be brought about by quinia. The subsequent 
treatment becomes mostly eclectic and rational, depend- 
ing upon the condition of the various organs, etc. If 
the head symptoms are j)rominent, we may continue the 
cold applications, leeches, or blisters to the nape, at our 
discretion. If the bowels require it, they are opened 
occasionally by emollient or laxative enemata; and 
when the liver is not acting healthily, a few grains of 
blue mass may be given every night or every other 
night, and there may be added to the mercurial a small 
quantity of ipecacuanha, Dover's powder, or opium, as 
the symptoms may require. If there be much heat, 
tenderness, etc., of the abdomen, fomentations, leeches, 
or a blister should be applied. In the latter stages, 
when the more decided dothinenteric symptoms present 
themselves, the oil of turpentine, in the form of emul- 
sion, with laudanum if necessary, or sugar of lead, 



TREATMENT OF THE MILD FORM. 185 

with opium, hyoscyamus, etc., or any other of the me- 
tallic astringent alteratives, associated frequently "with 
quinia or the compound tincture of bark, or, what some- 
times answers a better purpose, a pure article of wine or 
hrandy. These remedies, quinia, mercury, oil of tur- 
pentine, etc. are pushed according to the peculiar views 
of the practitioner." 

Outline of Treatment. — As it has been shown that 
enteric fever presents different grades of severity, so 
will it appear proper that the treatment should be alike 
varied to meet the indications of each form. I shall, 
under this caption, speak of the course of practice I am 
myself in the habit of employing in each of these forms 
of the disease. 

First. The Mild Form.— General bleeding I have very 
rarely practiced in either form — but three times, I be- 
lieve, in the 180 cases. But the local abstraction of 
blood by cups is with me a frequent practice. They 
may be applied to the nucha and temples when head- 
ache is severe, and upon the bowels when pain and ten- 
derness exist. An emeto-cathartic of calomel and ipe- 
cacuanha in the beginning, I am much in favor of, and 
never omit it unless the bowels are too much purged with- 
out medicine. After this I am in the habit of being 
content with a daily change of the body and bed linen; 

16* ,^ 



1S6 ENTERIC FEVER. 

cups, and poultices to the bowels, -when tenderness 
exists ; a draught of effervescing water, composed of 
citric acid and bicarbonate of potassa, several times 
during the day; a Dover's powder at night to procure 
rest, followed by one in the morning, if the bowels are 
acting too frequently; if not moved naturally every 
day, an occasional glass of Seidlitz water to influence a 
regular action; a little spts. nitre dole, after the first 
few days ; a cloth dipped in cold water and applied to 
the forehead, when headache is present : cold water for 
drinks, but not in too great quantities at a time; the 
veratrum viride to control the pulse, when it runs above 
110 ; occasional drinks of sol. chlor. potash ; and the 
regular allowance of a little food. 

Second. The Intermediate Form. — In this form, in- 
stead of sponging the surface with cold water, tepid water 
with vinegar, I think is best. Instead of the effervescing 
water, the spiritus mindereri is substituted, in the dose 
of a half fluidounce every three or four hours. To 
control the pulse, and thereby prevent damage of im- 
portant organs, the tr. verat. vir. is to be administered 
and pushed to the telling point, after which the dose is 
to be reduced, and its action maintained by its adminis- 
tration in sol. chlor. potash every three or four hours. 
"When there is tenderness on pressure over the bowels, 
free cupping should be employed, not with small cups, 



TREATMENT OF INTERMEDIATE FORM. 187 

but the largest ones to be had, followed by poultices of 
mush or warm buckwheat cakes, and, if thought ad- 
visable, these to be sprinkled with flour of mustard, and 
made large enough to cover all over the bowels, and ap- 
plied as often as they become cold, or until pain and 
tenderness are relieved. It is always 'best that the 
bowels should be suffered to remain moderately loose. 
Two or three discharges a day, I think, are of service, 
and if these do not take place naturally, some mild 
laxative should be administered. But should there be 
too great a looseness of the bowels, which is most com- 
monly the case, they may be restrained by a dose of 
Dover's powder, three or four times a day. It is in 
this and the subsequent form that the good effects of 
opium, when administered with due discrimination, are 
to be witnessed. A favorite formula with me is, tinct. 
opii., Hoffman's anodyne, aa giij; spts. lavender comp. 
3\j. Dose, a teaspoonful, given in the morning. For 
a night dose, six or eight grains of Dover's powder, with 
the addition of a little sulph. of morphia and camphor 
pulv. 

In many instances the above course of treatment is 
all that is necessary to conduct the case to an early 
convalescence. But should it happen that after the 
tongue has cleaned and become moist, the diarrhoea and 
tympanitis diminish, there is a sudden exasperation of 
these symptoms, the tongue, just rid of its coating, be- 



188 ENTERIC FEVER. 

comes red, smooth, and dry, with an increase of diar- 
rhoea and tympanitis, subsultus tendinum, etc., then 
opium with camphor should be freely administered. 
Should there have been no abatement of the symptoms, 
but a gradual progression toward gravity, and to that 
condition especially in which there is a dry, brown, or 
red tongue, the opium and camphor are equally benefi- 
cial. For this peculiar condition of enteric fever, as 
represented by the state of the tongue, other remedies 
have been highly extolled, and some of them deserv- 
edly so. Oil of turpentine and argenti nitras are both 
capable of effecting much good when properly and 
timely administered. Of the two articles the oil is en- 
titled to greatest credit. As already said, I have used 
both articles, and sometimes with marked advantage. 
For the relief of the same conditions for which the oil 
and argenti nitras is prescribed, I have also declared 
my confidence in the eificacy of opium. I repeat, when 
the condition of the brain will allow of its full employ- 
ment, it is capable of effecting a most salutary change 
of these symptoms, and the success of the cases which 
have passed through my hands, under its influence, has 
established a confidence I can repose in no other remedy. 

Third. The Malignant Form. — In this form of the dis- 
ease our object is to assist nature in her final struggle. 
In those cases with a red and dry tongue, as they pass 



TREATMENT OP MALIGNANT FORM. 189 

into this form, hemorrhage from the bowels not unfre- 
quently follows ; and in these cases I continue the 
opium in as large quantities as the patient can well 
bear, with a proper proportion of the sugar of lead. 
For hemorrhage from the gums and nostrils I like the 
employment of creosote;* this is to be used either by 
injecting into the nostrils, or pledgets of lint saturated 
in the solution and plugged into the nostrils ; for the 
arrest of bleeding from the gums it may be taken into 
the mouth and retained a few minutes, when properly 
weakened. For the arrest of diarrhoea, opium, alone or 
with chalk, argenti nitras, and the several vegetable 
astringents may be employed. If these means fail, in- 
jections of quinine and vinegar may be employed, and 
sometimes its effect is almost magical. If the bowels 
are not sufficiently evacuated, castor oil or rhubarb (the 
syrup of the latter is a good preparation) may be used. 
For the debility which attends this form, tonics and 
stimulants become absolutely essential; but in the 
allowance of these, the state of the pulse and the skin 
must be carefully considered. Washing the surface 
with brandy and water, and the internal exhibition of 
carbonate of ammonia, wine, and the sulphate of quinia, 
are eligible remedies. In some cases I have found it 
necessary to resort to pure brandy with quinine, and 

* Solution prepared by G. W. Carpenter & Co., Phila. 



190 ENTERIC FEVER. 

have witnessed the most gratifying results. Throughout 
this form of the disease the tr. verat. viride, in solution of 
chlor. potash, should be employed. It is capable of 
effecting great good, and may be employed in doses of 
from three to six drops every three or six hours. I 
have already spoken of the value of opium as a stimu- 
lant. When the brain is not involved, it is multum in 
2iarvo y and in this form of the disease is of signal ser- 
vice. In connection with camphor I have seen it quiet 
delirium, induce moisture of the surface, reduce the fre- 
quency of the pulse, and cause it to increase in volume, 
and promote gentle sleep, from which indeed the patient 
awoke "quite a different person." Throughout the en- 
tire progress of the case the state of the bowels, as re- 
gards tenderness, should not be lost sight of, but wet 
and dry cupping, as the case may require, with the con- 
tinued application of the poultices, and now and then 
the mustard-plaster, should be attended to. Blisters 
over the bowels I have not seen attended with sufficient 
good to give them importance. For the relief of mus- 
cular twitchings valerian has disappointed me less often 
than any other article of its class. I mean the pow- 
dered valerian in teaspoonful-doses every two or three 
hours. Retention of urine is a common occurrence. 
The importance of examining into the state of the blad- 
der daily, has already been sufficiently stated. A ten- 
dency to the formation of eschars, from pressure, should 



TREATMENT OF MALIGNANT FORM. 191 

not be forgotten. The parts exposed to pressure should 
be frequently washed with brandy, and the position of 
the patient as often changed. When obstinate deli- 
rium or coma exists, I have seen much advantage result 
from the timely application of a blister to the nape of 
the neck and the administration of a few blue pills. 

In those cases that present the symptoms of ma- 
lignancy in the beginning, the pulse full and strong, 
and obvious sanguineous determination to the brain, a 
moderate quantity of blood may be taken from the 
arm. But in the majority of such cases that have 
fallen under my management, I have preferred to trust 
to the effect of the cold douche, and thus far with en- 
tire satisfaction. As it is impossible for us to guess 
correctly the duration of any case of enteric fever, 
from any symptoms that may present, in the beginning, 
the general abstraction of blood should be cautiously 
practiced. But whether we bleed or not, it is important 
that the bowels should be thoroughly purged. Along 
with these cases, in the beginning, there is generally a 
torpid state of the bowels, and requires a larger dose 
than in the milder forms. In all these cases, if the pa- 
j tient be an adult, I give not less than twenty grains of 
! calomel, followed, in due time, if it does not operate, 
! by a dose of sulphate of magnesia or infusion of senna. 
! During the first few days free cupping on the back of 
i the neck, followed by a blister ; if delirium is obstinate, 



192 ENTERIC FEVER. 

cold applications to the head, a blue pill given at night, 
followed by a Seidlitz powder in the morning, is the 
course of practice I usually adopt, after which I omit 
the mercury and pursue the course of practice before 
described. 



CHAPTER X. , 

MANAGEMENT OF CONVALESCENCE. 

When convalescence has begun, the patient should be' 
closely watched, lest by some impropriety he be sud- 
denly cut off, even after having passed near unto 
death's door, and when his march toward health, with 
all its renewed charms and prospects, had well-nigh 
been completed. 

The most important part of the management of con- 
valescence refers to diet, regulation of the bowels, and 
exercise. 

The necessity of caution in the quality and quantity 
of food, at this time, is even greater than during the 
progress of the fever, and cannot be too strongly urged 
upon the attention of the attendants. From simple 
fluids — which were all that were required to satisfy the 
desires of the patient during his period of febrile ex- 
citement — to more stimulating and solid nourishment, 
the transition should be gradual. 

From inattention to this point in the management, a 
speedy and happy convalescence has been often gravely 
interrupted, and many instances are on record of death 

17 (193) 



19-1 ENTERIC FEVER. 

having resulted. No error is greater, and more com- 
mon among patients and their friends, than in supposing 
that debility is always to be removed by nourishing and 
stimulating food, wine or other stimulant beverages. I 
have seen convalescents suffer most severely from a 
single improper meal. In one instance, a female, in 
which the disease was of mild form, convalescence had 
so far advanced that the patient was able to be out of 
bed the greater portion of the day, for some two or 
three days, but not regaining her former strength in 
this time, the nurse, regardless of my strict injunctions, 
prepared a "nieal that looked like living" — roast beef 
and turnips, and of which the patient partook freely. 
In a few hours afterwards she went to bed with pain of 
the stomach, thirst, and high fever, and soon succeeded 
a pulse of one hundred and forty. The disease ran 
through its entire course again, and in a much graver 
form. 

The first change of diet should be to another article 
of the same kind of food as was allowed during the 
progress of the disease: for example, from simple 
arrow-root mucilage to arrow-root and milk, or to some 
other of the farinaceous compounds. From this ad- 
vance maybe made to Indian-meal mush and milk; 
rice, well boiled and served up with milk and sugar, 
nutmeg, or other spice; rice-puddings, and custards, 
etc. If the patient desire it he may partake of some 



MANAGEMENT OF CONVALESCENCE. 195 

of the fruits — the orange, apple, strawberries, mulber- 
ries, and grapes — when freed of the skin and seeds. 
In the allowance of animal food, it is best to begin with 
broths: of chicken, squirrel, beef, or mutton. On ac- 
count of its less stimulant nourishment, and easy diges- 
tion, the ivhite fish, when boiled, is well fitted for the 
early stage of convalescence. When wine is allowed, 
attention should be paid to the kind and quantity. 
Sherry and claret are, perhaps, preferable. In fixing 
the quantity to be allowed, the age, the degree of de- 
bility, and previous habits of the patient, should be 
taken into account. It should be remembered that 
young persons and females are more easily excited by 
stimulants of this class than older persons and males; 
that young persons, as a general rule, convalesce more 
rapidly than the aged; and, therefore, they require less 
wine in proportion. If the patient, when in health, 
have been in the habit of taking wine or other alcoholic 
stimulant, he will require wine in more liberal quantities 
than if he had been strictly temperate, both during the 
fever and in convalescence. As health becomes con- 
firmed, it should be gradually withdrawn. 

With respect to the number of meals, and the periods 
best adapted for taking them, no specific rules can 
apply. 

Constipation of the bowels is a common condition of 
convalescence. This is to be overcome, if possible, by 



196 ENTERIC FEVER. 

a properly regulated diet; if not, laxative medicines, 
such as rhubarb, castor oil, etc., or injections must be 
resorted to. The subjoined mixture answers an excel- 
lent purpose in obviating troublesome constipation : — 



I£. — Ead. columbse contus, 


fss ; 


Fol. sennae, 




Bs 


Extr. taraxaci, 






Manna, aa 




iss; 


Aqua fervent, 




5xij ; 


Macera per horam 


, cola 




et adde Holland 


gin, 


ijv. 


Misce sumat cochleare 


mag. j vel ij pro dosi. 



When convalescence becomes tedious, and profuse 
and exhausting sweats occur at night, much benefit will 
accrue from the administration of the aromatic sulphuric 
acid, or some one of the simple bitters. "Convales- 
cence appears to be sometimes very much retarded by a 
debility of the alimentary canal, which disables the 
ulcerated surfaces from healing. A species of hectic 
excitement is sustained for a long time. The pulse re- 
mains frequent; something like a febrile paroxysm 
occurs every afternoon, and the patient sweats copiously 
at night. Under these circumstances, I have found 
nothing so effectual as sulphate of quinia." — Wood. 

With regard to exercise, not less care is required 
than concerning the allowance of food. Convalescents 
soon grow tired of their beds, and not a few, if unop- 



MANAGEMENT OF CONVALESCENCE. 197 

posed, will overtask their feeble strength by long sit- 
tings out of bed. Errors of this sort have not unfre- 
quently been followed by very bad consequences. In 
quitting his bed the patient should do so gradually. 
Even should the observance of this advice be unneces- 
sarily strict, no danger can result; whereas if disre- 
garded, dangerous if not fatal consequences may be 
incurred. Especial care is to be observed in the return 
to out-door exercise. The patient may have regained 
sufficient strength to allow of his being out of the bed 
the greater part of the day, but he should not on this 
account thrust himself out of doors. Injury has often 
resulted from venturing out too early during the cold 
weather of winter and spring. Dr. Tweedie remarks : 
" That many persons who have struggled through a 
most dangerous fever have, from imprudent exposure 
to cold, been seized with intense inflammation in some 
organ, which has rapidly destroyed life." 

During convalescence every source of mental exer- 
tion should be strictly avoided; the mind should be en- 
gaged without being oppressed. Much advantage may be 
afforded the patient by a proper selection of visitors, for, 
above all things, the presence of idle gossipers should 
be avoided. These wiseacres, with which the country 
is infested, are usually very kind and prompt in their 
* attentions to the sick ; so kind indeed, that they almost 
invariably leave an infallible prescription of medicine 

17* 



198 ENTERIC FEVER. 

or diet at each successive visit, which benefited Mr. or 
Mrs. So-and-So, who was for all the world in a similar 
condition, and it was used by Dr. Somebody. 

One or two other remarks and I shall have ended 
these pages. 

Boils are more or less apt to form on various parts 
during the establishment of health. If the patient have 
been blistered on the neck, they are most likely to oc- 
cur in this locality, and sometimes a succession of these 
painful affections will worry the patient for months. 
In the beginning they may be completely destroyed by 
plunging a lancet exactly through the centre of the 
forming pimple. The success of this simple procedure 
is exactly in proportion to its early resort, and on 
which account the incision should be made, if possible, 
during the first day or two; but it is better to do it even 
as late as the fifth or sixth day, than not at all. When 
a succession of these pustules are likely to occur, the 
patient should be advised a course of quinine. Dr. 
Jackson's advice is surely correct, which simply told is 
this : the least done in the way of poulticing the better. 
Dressings of simple cerate are all that is necessary. 

Alopecia, or falling of the hair, is a common sequence 
of enteric fever. The production of the new suit of hair 
may be aided by gentle frictions to the scalp, and keep- 
ing it warm. Benefit may also accrue from the use of 
some of the stimulant pomades. The following, recom- 



MANAGEMENT OF CONVALESCENCE. 199 

mended by Dr. Copland will be found as good as any- 
other : — 

I£. — Adipis praeparati, §ij ; 

Cerse albse, fss ; 

Lento igne simul liquefac, tunc ab igne re- 
move et ubi primum lentescant ; 

Balsami Peruviani veri, 3ij ; 
Olei lavandulse, ""Ixij. 

Adjice et assidue move donee refrixerint. 

Having in a concise and simple manner completed 
the task assigned to myself at the commencement of 
this volume, I submit the result to the candor of an 
honorable and intelligent profession, trusting that even 
if nothing of importance be added to the information 
already possessed by my medical brethren, it may serve, 
in some humble measure, to direct their attention to a 
more careful study and a better understanding of a 
wide-spread disease, fearful in its character, tendency, 
and complications. 



C 



THE END. 

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